
(SojpghtN 



COPYRIGHT DEPOSIT. 



CLINICAL TALKS 



ON 



Minor Surgery 



% By 

JAMES G. MUMFORD, M.D. 

Assistant Visiting Surgeon to the Massachusetts 

General Hospital, and Instructor in Surgery, 

Harvard University Medical School. 



BOSTON 

INCORPORATED 
27 AND 29 BROMFIELD STREET 



[-HE LI 5KARY OF 
CONGRESS, 

I903J 



- I 




Copyright, 1903 
By James G. Mumford, M.D. 



W$t JFort pjiii Press 

SAMUEL USHER 

176 TO 184 HIGH STREET 

BOSTON, MASS. 



TO 

Maurice Howe Richardson, M.D. 

In recognition of eighteen years of instruction in good surgery, 
this little book is cordially inscribed by 

The Writer 



NOTE 

This series of brief talks is the outcome of an inti- 
mate dealing as a teacher with medical students for 
some ten years, and a realization of certain of their 
needs. I have treated here of homely, commonplace 
subjects. Such subjects find little place in the text- 
books and lend themselves but feebly to brilliancy of 
demonstration. 

The cases described and the printed words are 
reproductions of actual experience. 

J. G. M. 

29 Commonwealth Avenue, 
Boston, May, 1903. 



CONTENTS 



PAGES 



Lecture I. The Examination and Study of Cases i 

Lecture II. Incised Wounds . . . 13 

Lecture III. Simple Fractures ... 27 

Lecture IV. Lacerated Wounds 36 

Lecture V. Compound Fractures ... 45 

Lecture VI. Granulating Wounds and Varicose 

Ulcers 56 

Lecture VII. Felon, Whitlow, Paronychia, Palmar 

Abscess • &7 

Lecture VIII. Boils, Carbuncles .... 81 

Lecture IX. Bunions, Ingrowing Nails, Corns, and 

Warts 93 

Lecture X. Massage 104 



Clinical Talks on Minor Surgery 



LECTURE I 

THE EXAMINATION AND STUDY OF CASES 

Gentlemen: About twelve years ago, some one 
coined the phrase " antiseptic conscience." I 
think it /was Dr. Kelly of Baltimore. That 
phrase and the thought it contains were once 
essential, because twelve years ago most of the 
men who were doing the surgery of the world 
belonged to the generation which in its youth 
knew the old sepsis. To them the principles 
and practice of antiseptic surgery came halt- 
ingly and often imperfectly. They had indeed 
need to cultivate the antiseptic conscience: 
but they had conscience for many other things, 
— great principles underlying good surgery, 
principles as important to-day as ever they 
were. One is impressed at times with the con- 
viction that many of those sound, ancient 



2 CLINICAL TALKS 

principles latterly are being pushed back into 
a very subordinate position. 

To-day a majority of the surgeons in active 
practice have grown up with the antiseptic 
idea. In the course of their development, the 
antiseptic conscience has become part of their 
being. That intangible thing which we call 
surgical instinct includes and partakes of that 
same conscience. There is no danger -of any 
man who has received his training in the past 
twenty years going far astray, with that con- 
science to prompt him. Every source of surgi- 
cal infection has been so thoroughly and univer- 
sally studied that, with one or two exceptions 
which I must speak of later, our technique is 
now perfect, or as near perfection as it is likely 
to become. 

But there are those other principles which 
were so important to the former generations. 
Are you students of to-day aware of them? Is 
it not a fact that you have come to look upon 
asepsis as the one thing needful, and to feel 
that, asepsis being accomplished, there is noth- 
ing more to be done? Are you to be as good 
clinicians as were your surgical forebears? 
That is a question which your teachers often 
ask themselves; over which they hesitate in 
the answer. 

If I name some of those general principles to 
which I refer they seem commonplace enough, 



ON MINOR SURGERY 3 

and most of you will say, perhaps, that you 
have them always in mind; but such is not 
by any means the conclusion of observers 
who watch the detail of work in our great 
hospitals. 

The most important lesson which a surgeon 
has to learn is to estimate the patient's general 
condition. I put that, as essentially above 
any question of therapeutics. That matter 
of the general condition is a very large part of 
diagnosis. You have various routine questions 
which you ask in a perfunctory fashion: the 
patient's age, birthplace, residence, occupa- 
tion, family history and previous condition of 
health, and in some sort you learn the answers, 
— but those answers are not idle babble; they 
have a very real bearing on the matter in hand. 
Here, in this surgical clinic, you are altogether 
too prone to assume that every case you see is 
an operative one pure and simple, and you look 
no further. Gentlemen, I am forced to admit 
and I admit it with chagrin, that the fault lies 
largely with us, your surgical teachers; it is 
one of the deplorable results of specialism gone 
mad. In the old days, it was required of the 
surgeon that he have a good practical working 
knowledge of general medicine. Operations 
were a last resort; John Hunter and Liston told 
their classes that the knife was an opprobrium, 
and should be used only when all other means 



4 CLINICAL TALKS 

failed. Of course that extreme view has long 
ceased to prevail; — modified, first, by the in- 
troduction of anaesthetics and later by the 
development of asepsis. Indeed for long the 
pendulum was swinging the other way, when 
the knife was deemed the only reliable meas- 
ure. Now, again, thanks to increased knowl- 
edge, we are appreciating that there are other 
resources. 

Every one of those data which the clinical 
clerk takes down by rote may be of the greatest 
importance. Age may rule out many things, 
such as cancer, arteriosclerosis and the like; the 
place of birth and the race may suggest tuber- 
culosis or malaria, as may the residence. The 
other day I saw a case of anthrax of which the 
diagnosis was rendered probable by the patient's 
surroundings ; there are numerous occupation 
diseases, — lead-poisoning and ' 'housemaid' s- 
knee ' ' will at once occur to you. That matter 
of family history or hereditary tendency is im- 
portant, in spite of the new light we are con- 
stantly getting on the whole question of eti- 
ology ; and especially the patient's previous 
condition of health is to be studied. 

Here is a patient who illustrates in his own 
person many of the points we are considering. 
You see he is a young man. His age is twenty- 
three. He is of American parentage and of 
vigorous stock. He was born, reared, and now 



ON MINOR SURGERY 5 

works in a neighboring town, which has been 
notorious for its unwholesome location, — 
being low-lying, ill drained, and inadequately 
supplied with water. The young fellow is 
assistant to a sewer contractor, and spent most 
of last summer overseeing a gang of men 
engaged in laying drains. In September he 
became ill with typhoid fever, as appears from 
his physician's statement and the story he him- 
self tells. Typhoid was epidemic in his town. 
Recovering, after an illness of some two months, 
he returned to work. After an interval of six 
months — that is to say, two or three days ago, 
— he was seized with acute pain in the region 
of the right shoulder. The pain increased, and 
is now very severe, — of a boring, throbbing, 
agonizing character. You see for yourselves 
that the patient looks like a sick man. He is 
flushed, with a coated tongue, the bowels are 
constipated, the urine is scanty and high col- 
ored. The man supports his arm in his hand; 
he favors it, as we say, and is evidently in great 
suffering. On examining him you find his 
pulse to be bounding and rapid, with a rate of 
116, and a blood pressure recorded as 190 by 
the Riva-Rocci apparatus. 

When you come to handle the arm, you find 
some slight swelling and a sense of bogginess 
about the shoulder joint; but the joint itself 
is not especially tender on pressure and the 



6 CLINICAL TALKS 

patient seems to refer his pain rather to the 
head of the humerus. 

Here is a very definite picture, gentlemen, 
On the history alone you should be able to make 
a correct diagnosis. The man is obviously the 
victim of an acute infectious process. He has 
been for long exposed to unsanitary conditions, 
and he has recently had typhoid fever. My 
assistant has just now found the leucocytosis 
in his case to be 40,000, and the temperature 
io 4 °F. 

What are we to conclude from this collection 
of signs and symptoms? There are but two 
processes which suggest themselves at once — 
an acute articular rheumatism and an acute 
osteomyelitis. To distinguish between these 
two conditions is of the utmost importance. 
In the two diseases the signs and symptoms 
are in very many respects identical; but we 
have two points as guides: the bone rather 
than the joint is the seat of pain, and the patient 
has recently had typhoid fever. We know 
that acute infectious diseases are frequent pre- 
cursors of osteomyelitis, and we are justified 
in concluding that we are dealing here with 
that process. A correct decision is urgent. 
The patient will be admitted to the hospital 
at once, the shaft of his humerus will be opened 
and drained, and he will doubtless recover with 
a useful arm. A few days' or even hours' delay 



ON MINOR SURGERY 7 

might mean for him a systemic infection, sep- 
ticaemia, and death. 

To take up the thread of our main topic 
again; there is that indefinable thing we call 
the patient's General Condition. Believe me, 
you cannot too soon begin to bear that thought 
constantly in mind. Old Sir Benjamin Brodie 
used to say that he could often make a diag- 
nosis by the smell of a patient's bedroom. It 
is unnecessary for us to know such shrewd 
tricks as that, but you must learn to put all 
your senses into action. You come here to 
this clinic, fresh from your laboratory studies. 
Hitherto you have learned only the uses of the 
sense of sight, now you must cultivate your 
hearing, touch, and even smell, like old Sir 
Benjamin; and you must come gradually to 
appreciate that nebulous aura of physical condi- 
tion which every man, sick or well, carries with 
him. When to these things you add those 
instruments of precision, the uses of which you 
are learning, there will be an accuracy and 
finality to your decisions which were impossible 
for the ancient men. 

You will conclude from what I have said 
that a competent surgeon must be a very thor- 
oughly-equipped all-round man. Exactly that 
is my meaning. You must study your general 
medicine as well as your surgery, and you must 
follow carefullv both sets of clinics. There was 



8 CLINICAL TALKS 

a time, fifty years ago and less, when all sur- 
geons were general practitioners. Then with 
the development of specialties came a natural 
and proper narrowing of the surgeon's field. 
For years we devised new operations, we at- 
tacked organs previously regarded as inaccessi- 
ble, we learned and perfected a new practice 
and a new technique. It has come about with 
this development of our branch of the art of 
medicine, that many diseases as well as organs 
have become the surgeon's own, his own in part 
at least, — diseases and organs with which he 
never thought to tamper a few years ago. So 
again it is becoming apparent that he must be 
familiar with a great variety of processes which, 
a few years ago, concerned him little if at all. 
In that second stage of the surgeon's develop- 
ment, he was often little more than a thorough 
anatomist and a clever handicraftsman. We 
have outgrown that stage. We now realize 
that the surgeon must know and be ready to 
apply the principles of physiology, chemistry, 
pathology, and bacteriology as well as those of 
anatomy and physics. He deals with almost 
every known disease and with every organ of 
the body. He must be familiar with the struc- 
ture and function of those organs, the nature 
of their disease processes and the appropriate 
methods of treatment, if he is to put to their 
best and proper uses the therapeutic measures 



ON MINOR SURGERY 9 

with which he is especially equipped. He 
must not stand idly by until his medical con- 
frere says "'cut.'" He must cut when the time 
comes of course, but must use his now matured 
judgment to sustain the advice of his colleague. 

Before now, following the old blind method, 
the chest has been opened for empysema, when 
no pus was there; the appendix has been re- 
moved when typhoid fever was the cause of the 
symptoms, and the gall bladder has been opened 
for the cure of lumbricoid worms. I have even 
known a colleague to scoff at a surgeon who 
used a stethoscope, and to look upon a micro- 
scope as an instrument outside of his. ken. 

In all this, do not misunderstand me. A 
surgeon's duty is the treatment of disease by 
proper and recognized surgical measures; but 
he should have a sound knowledge of all disease 
as well, recognizing his own limitations; and 
while his medical colleague is at work with his 
proper investigations and remedies, the surgeon 
should stand by, waiting to be called upon for 
the employment of his own peculiar skill. 

Given then the particular case, such as that 
of the man with osteomyelitis: You have 
looked the ground over, have ascertained the 
gravity of the general condition, and now turn 
your attention to the special lesion under con- 
sideration. That lesion is in the arm near the 
shoulder joint; and without further doubt you 



io CLINICAL TALKS 

make your diagnosis and recommend appropri- 
ate treatment. But take this other patient 
whom I show you as a foil to his fellow. He, 
too, is a young man, — not more than thirty- 
five; his previous condition of health is unim- 
portant, and he, too, has a disease near the shoul- 
der joint. It is in the nature of a swelling or 
tumor, and he has had it for some fifteen years. 
It is a chronic process, therefore. 

When you see a swelling there are two ques- 
tions which should suggest themselves to you 
at once : Is this an inflammatory process or is it 
a neoplasm? For the purposes of practical 
exclusion you run over rapidly in your minds 
the old formula which applies to acute inflam- 
mations — Is there pain, heat, redness, swell- 
ing, and impairment of function? In this case 
all of these are absent save swelling; moreover, 
this is a chronic process. Then you call up 
your other familiar formula which applies to a 
swelling — What is its exact location, size, shape, 
color, consistency? You must have these two 
formulae always in mind; always on your 
tongue's tip, and be ready with your answers. 
This swelling has none of the characteristics of 
inflammation and the patient's general condi- 
tion is excellent. Therefore it is probably a 
neoplasm and of a benign type. You say it is 
situated just below the acromion process over 
the middle of the deltoid muscle. It is about 



ON MINOR SURGERY u 

the size of a small orange; it is spherical and 
uniform in outline; its color does not differ 
from that of the surrounding skin; it is soft, 
rather gelatinous to the touch, but it does not 
distinctly fluctuate. It is subcutaneous, mov- 
able, not adherent to the skin, and the adjacent 
glands show no metastasis. 

Observe carefully the method of approach- 
ing your patient and handling the little mass. 
See that he sits or stands at ease before you, 
with a good strong light upon him while your 
own back is turned to the window. Gain his 
confidence by assuring him that you do not 
expect to hurt him. He will then sit relaxed 
and will not shrink or grow tense at your touch, 
— an important desideratum. Now pass your 
extended palm gently over the tumor, once 
or twice. In that way you will gain a 
great deal of information, and if the parts are 
sensitive, you will give no pain. The tactus 
eruditus does not belong to the heavy-handed 
surgeon. I cannot too strongly urge upon you 
the great advantage and importance of gentle- 
ness. Your patient will recognize it at once. 
He knows when he is being handled by a man 
who knows his business. The reputation of 
being a rough or brutal surgeon helps no one. 

You will see the thoughtless, inexpert man 
plunge at a painful, sensitive region as though 
he were kneading dough. You can tell the 



12 CLINICAL TALKS 

neophyte at once by his roughness. The gentle 
outspread palm and fingers of the examiner 
are extremely sensitive to tactile impressions 
and can be educated to a rare facility. It is 
seldom necessary to prod and poke with the 
finger tips. 

Passing my hand over this tumor I readily 
define its outline, its extent, its density, its 
mobility, and I note the absence of sensitive- 
ness. Now if I choose, I can pick it up in my 
finger-tips and determine, if necessary, its lack 
of fluctuation and the depth of its attachments. 

That is the whole story. You have the list 
of benign tumors in mind and, running over 
them, you see at once that this must be a fatty 
tumor or lipoma. After all, it makes little 
difference what you call it. The method of 
your examination concerns us at present, and 
if you have learned to take a broad view of 
your case, to approach it without rush or flurry, 
and to observe accurately those few important 
details of which I have spoken, the giving a 
name and the assigning treatment will natu- 
rally and readily follow. 



LECTURE II 



INCISED WOUNDS 



Gentlemen : Twenty years ago Mr. Sampson 
Gamgee published in London one of the very 
best books in English that is known to me, on 
the treatment of wounds and fractures. 

After describing in some detail the patho- 
logical conditions which are met with in these 
phenomena, he goes on to lay down the car- 
dinal principle of support for the injured part, 
and this he recognizes as the one essential in 
the therapeutics of traumatic surgery. 

I shall have much to say as to the meaning 
of that word " support." In the time of Mr. 
Gamgee's writing, the word asepsis, in the 
modern sense, had hardly been invented; but 
it has now come not altogether justly to usurp 
the honors of surgical support ; for in the consid- 
eration of all wounds, whether of the soft or 
hard parts, in which there has been any sort of 
disturbance of continuity, you should have 
constantly in mind that that severed continuity 
must promptly be restored; that those restored 
parts must be absolutely immobilized and sup- 

13 



i 4 CLINICAL TALKS 

ported, and that this work must be done under 
aseptic conditions. 

I show you here a simple case in point. This 
man is a tinsmith, thirty years old, sound and 
vigorous. About two hours ago, while at his 
work, he cut through the skin and fascia of 
his palm, leaving as you see, a clean, straight 
wound, extending about three inches across 
the hand. 

Let us see how we may apply our two prin- 
ciples, support and asepsis. We must regard 
what we have to do as a surgical operation. 
The whole field of the wound — and in this case 
the field is the man's hand — is sterilized, so 
far as may be in the manner with which you 
are familiar, — a thorough scrubbing with soap 
and water, followed by immersion in chlorin- 
ated soda and wiping with cotton sponges 
dipped in pure alcohol. The hand is then 
immersed for two minutes in an alcoholic so- 
lution of bichloride of mercury, i to 3,000. The 
hand and arm are then wrapped in a clean, 
steamed towel, and the patient sits before me 
with his arm outstretched, palm upward, upon 
the table. Meanwhile I have cleansed my own 
hands with soap, water and alcohol, and have 
put on rubber gloves, which have been steril- 
ized by boiling. I have gone into this matter 
in some detail with you, because details in 
asepsis are the sine qua non of successful sur- 



ON MINOR SURGERY 15 

gery, and I do not expect to repeat again what 
I have just told you. 

Let us now examine the wound. We must 
be sure always that no foreign substance re- 
mains in its depths, and in this case we find 
none. As I hold the wound open, you see the 
extensive tear in the palmar fascia. Perhaps 
I am overscrupulous in closing this, but I 
believe that by so doing I shall hasten the 
restoration of function. I close it, as you see, 
with three interrupted catgut stitches, using 
the curved needle rather than the straight one. 
That leaves me the skin wound of the palm, 
which lies together without gaping. The 
severed edges are dusted with a simple drying 
powder, aristol; a bit of crepe lisse laid across 
and secured with collodion further supports 
them. I then apply a bit of absorbent cotton 
also held down with collodion about the edges, 
forming what we call the "cocoon dressing." 

Now you will say that sufficient has been 
done to assure a prompt and sound healing by 
the first intention; but I ask you to observe 
that the second only of our cardinal principles 
has been applied up to this point. A reason- 
ably accurate asepsis has been provided; why 
is not that sufficient, and why do I go on to 
apply the first principle — support and im- 
mobilization ? A very simple experiment on 
your own fingers will illustrate the reason. If 



1 6 CLINICAL TALKS 

you prick your finger sharply, tie an elastic 
band around it and let it hang down for a few 
minutes, you will find that the whole finger 
shortly will throb painfully, and the pricked 
wound will smart and ache. Xow remove the 
rubber band, place the hand upon the opposite 
shoulder, and hold it there steadily; you will 
quickly experience relief and a sense of com- 
fort. The series of phenomena which you have 
experienced are not dissimilar from what will 
occur in this man's wounded palm. Were I 
to leave his hand unprotected, except for the 
cotton and collodion, he would naturally swing 
it at his side. Almost at once the process of 
repair will have begun — there will be the in- 
evitable increased blood supply in the wounded 
parts, a certain amount of exudation will go 
on, the venous circulation will be slightly im- 
peded, and all these conditions will be accent- 
uated by hypostasis, if his hand hangs down; 
in other words, the reparative process will be 
interfered with. 

You know that hitherto we have been able 
to devise no means of disinfecting thoroughly 
the skin. The epidermis may be scrubbed 
and treated with chemicals until it is fairly 
free from micro-organisms, but the corium 
cannot be touched by such methods, and in the 
corium normally there are to be found patho- 
genic organisms, mostly the staphylococcus 



ON MINOR SURGERY 17 

epidermidis albus. You must bear in mind, too, 
that in the aseptic operations of surgery we 
have three principal sources of infection to 
consider: First, the instruments; second, the 
dressings and suture materials; and, third, the 
skin, whether of patient or operator. At the 
present time we have advanced so far that we 
have eliminated the first two sources. Instru- 
ments properly boiled carry no organisms; 
dressings and suture materials properly steamed 
and prepared are sterile. So we come to the 
third source, the skin. Even that to a large ex- 
tent may be ruled out, for we now wear aseptic 
gloves, — surgeons and all assistants, — so that 
we are left with the patient himself as the one 
most important carrier of possible infection; 
and after the most scrupulous care in prepara- 
tion, the patient's skin must carry in its deep 
parts pathogenic organisms, as we have seen. 
One asks, Why do not these bacteria always 
produce sepsis? Because to do so they must 
be present in great numbers, or else they must 
fall upon suitable soil, or both. 

I need not review with you here the well- 
known fact that in varying degrees patients 
carry in their own tissues disease-resisting ele- 
ments; suffice it only to remind you that or- 
ganisms which will grow and multiply in and 
infect one man will fall harmless upon another; 
and here is your practical point, that in a great 



18 CLINICAL TALKS 

many cases, by appropriate treatment you 
may help to bring nearer to immunity, you 
may fortify the resisting powers of your indi- 
vidual patient. There again, as I said at our 
last exercise, you see the importance of study- 
ing your patient's general condition. 

So it is practically in the patient's own skin, 
and there chiefly, that we must look for a source 
of sepsis. 

What became of these organisms at the time 
this man received this cut? Some of them 
were undoubtedly carried into the deeper parts, 
some of them still remain on the cut edges, and 
others will be forced into the wound itself and 
into the general circulation during the early 
hours of repair. Now this man's hand has 
been relieved of a large number of organisms 
by our antiseptics. We must strive to render 
the deep parts of the field infertile. No better 
medium exists for the growth of organisms 
than a stagnant or sluggish blood supply, and 
that condition exists to perfection when we 
leave the man's hand hanging at his side. I 
now place it high upon his chest and secure it 
in a sling. 

We have now provided for asepsis and eleva- 
tion. Is there anything further that may help 
to hasten his recovery? There is, and it is that 
surgical immobilization to which I have already 
called your attention. 



ON MINOR SURGERY 19 

If I leave the hand unconfined except by the 
light, supporting sling, there will be nothing to 
prevent his withdrawing it from the sling, and 
there will be nothing to prevent his using the 
hand and fingers even if elevated. 

Here, again, you may ask, What harm can 
possibly result from such use? We have con- 
ceived of an exudation essential to the heal- 
ing process in the palm; we have conceived 
of an increased flow of blood to the part; 
we can further see how the support of 
the arm has improved the venous circulation, 
and it takes very little imagination to under- 
stand how the action of the muscles dragging, 
pulling and contracting may well keep up an 
irritation which, superadded to the other con- 
ditions, will stimulate a bacteriological activity 
and initiate a sepsis. 

These are involved conceptions, but are re- 
quired to illustrate a condition which, after all, 
is simple enough; again we come back to our 
point and say that the one thing left and 
needful for the repair of this man's wound is 
immobilization. 

Perfect immobilization, in the surgical sense, 
is far from being the simple thing you might 
suppose. It is not readily attained; and with- 
out giving careful thought to the anatomy of 
the parts, it cannot be attained. Take the 
instance of this man's wounded hand. What 



2o CLINICAL TALKS 

are the important structures which go to make 
up the anatomy of the palm and adjacent parts? 
Obviously they are the skin and fascia, the 
underlying tendons and muscles, and the bones. 
We cannot keep the wound in a state of surgical 
rest unless we immobilize the adjacent struct- 
ures, and that means that we must tie up the 
muscles of the part. Those muscles are the 
extensors and flexors of the hand, and their 
origin is about the condyles of the humerus 
and in the forearm, a fact elementary and 
obvious enough, but surprisingly overlooked 
often. So we must carefully bandage and 
restrain the movements of the forearm. Ob- 
serve now a point which I must emphasize 
repeatedly. Never apply for immobilization 
a bandage close to the skin or over a thin inter- 
vening pad. Learn always to use elastic 
compression. You see that I now cover this 
patient's hand and forearm with six or eight 
layers of sheet wadding, — an elastic, very 
slightly absorbent material, which will not be- 
come caked and matted with perspiration. Be- 
tween alternate layers of the wadding I place 
four strips of moistened mill board — two laid 
straight down the arm and two twisted spirally 
about it. These harden as they dry and lend an 
added stiffness and elasticity to the dressing. 
So far the application looks very cumbersome 
and unwieldy, but with this cotton roller I 



ON MINOR SURGERY 21 

now carefully and snugly bind the whole into 
place. I pull the bandage very tight, greatly 
diminishing the bulk of the dressing, so that 
when completed it appears to be of moderate 
proportions. If you handle the completed 
dressing you find that it is quite elastic to the 
touch, and that it exerts everywhere a perfectly 
equable compression. It controls absolutely 
the muscles; no movement can go on under- 
neath it, yet it is extremely comfortable. It 
is tight, but it does not constrict. By its firm 
contact everywhere with the underlying parts 
it moderates and controls the circulation, but 
it does not occlude it. Here you have illus- 
trated on a large scale the principles of com- 
pression which you apply when you seize and 
compress gently and bring comfort to your 
sore thumb, which throbs and aches with the 
beginning of a "run-round." So now you see 
employed the four remedies which you must 
learn to apply in the dressing of all wounds: 
asepsis, elevation, immobilization, and com- 
pression, and the last three imply support, — 
remedies which may be modified in degree 
often to suit special conditions, perhaps em- 
ployed with over-scrupulous care in this par- 
ticular case, but always important, always to be 
borne carefully in mind; to become as much a 
part of your instinct and training as that anti- 
septic conscience of which we have heard tell. 



22 CLINICAL TALKS 

Here are two cases which illustrate the re- 
sults of proper and improper treatment. This 
lad received a ragged four-inch wound of the 
wrist from falling on a broken bottle some ten 
days ago. The skin cut you see, but I must 
tell you — a fact not so obvious — that the * 
superficialis volae artery and one tendon of 
the flexor sublimis digitorum were severed. 
When brought in here, about three hours after 
the accident, the boy's arm was found tied up 
tightly with a knotted handkerchief, the wound 
gaping and ugly looking, where cobwebs — a 
favorite domestic remedy — had been smeared 
over it, blood still oozing from the artery, and 
the whole hand livid, swollen, and very painful. 

The patient was laid on the operating table, 
the handkerchief removed, the arm elevated 
in the air and supported by an assistant for 
about five minutes, when the bleeding was 
found to have ceased, the swelling to have sub- 
sided, and the hand to be normal looking and 
painless. Then the whole arm and hand were 
cleaned and disinfected — washed, scrubbed, and 
soaked, as I have shown you, not dabbed at 
and mopped over with a futile corrosive sponge. 

The two ends of the cut vessel were secured 
and tied with catgut, the severed tendon was 
united by fine silk stitches, the skin edges care- 
fully and accurately approximated with four sil- 
ver wire points, — which I prefer in the case of 



ON MINOR SURGERY 23 

these ragged cuts of the wrist, — and the hand 
and arm put up in the manner I demonstrated 
to you in the case of the tinsmith. In this case, 
of course, the wrist was secured in a position 
of slight flexion to relieve tension on the severed 
tendon. Since the day of the first dressing the 
patient has felt perfectly comfortable; his 
temperature has been normal and his bodily 
functions have been undisturbed. Twice dur- 
ing this time an additional tight bandage has 
been applied over the dressing, which had be- 
come somewhat loosened. 

The apparatus has now been removed, and 
I call your attention to the appearance of the 
hand and arm. The entire limb is pale and 
shrunken. That is as it should be. The hand 
looks thin and normal, the fingers are flexible 
so far as I allow them to be moved. The 
wound is a simple red line — not puffy, not 
tender, not painful. The old cocoon dressing 
shows a little dry blood-stained exudate. I 
remove carefully the silver stitches which have 
admirably supported the irregular skin edges, 
and the wound is found practically healed. 
Of course there is more to the case. That ten- 
don wound will be slow in healing, and the hand 
must be protected and supported for some 
weeks on that account, but so far as our simple 
incised wound is concerned it need trouble us 
no more. The dressing was dry and it was in- 



24 CLINICAL TALKS 

frequently renewed. Napoleon's famous sur- 
geon, Baron Larrey, was the great exponent 
of that method a hundred years ago. When 
you can find the time, read what he says in his 
delightful ''Memoirs" on the subject of infrequent 
dressings. 

Here is a man whose story is not so happy. 
He is a postman. Five days ago he received 
a cut on the back of the left forearm, being 
struck by a piece of falling window glass. The 
cut was about six inches long. Only the skin, 
thick fascia and some fibers of the muscles 
of the extensor group were cut. There was 
little bleeding. The wound was cleaned and 
covered in with the greatest care, but a sup- 
porting bandage and sling were omitted, at the 
man's request, as he said they would interfere 
with him and that he would be careful not to 
use his arm. 

He reports here for the first time this morn- 
ing, after five days of active running about, 
swinging the arm at his side. You see the 
state of his wound and compare it with that of 
the lad with the severed tendon. Here is a 
distinctly reddened area extending for an inch 
all about the cut, the edges of which are in- 
fected and slightly swollen. I remove one 
stitch and find it is followed by a drop of pus. 
The man says that the wound has ached for the 
past two days, and that he has felt ''feverish" 



ON MINOR SURGERY 25 

and uncomfortable. We find his temperature 
to be 9 9. 4° F., as you see. The arm has not the 
shrunken, cool, almost anemic look that we saw 
in the last case, but is distinctly warm and full. 
Fortunately, no great damage has been done as 
yet. By appropriate treatment the initial sep- 
sis may be checked, but the man has delayed 
his convalescence by several days, and we have 
a series of troublesome dressings to occupy us, 
which I shall explain on a subsequent day. 

So much for the three cases of simple incised 
wounds. They have been striking types and 
have told their own story, yet I must qualify 
that story in a few words, else you would leave 
this room with a false idea of the possibilities 
and limitations of our art. 

All incised wounds carefully cleaned and put 
up with compression ^nd elevation do not heal 
promptly, nor do all wounds, lacking that sup- 
port, become septic. If there is any one 
thing true of surgical therapeutics it is that 
there is in it no place for dogma. Beware of 
the surgeon or physician who says, thus and 
thus shall it be done and no otherwise. Such 
precepts make of surgery an exact science, 
which it is not, and the men who presume to 
apply to it ironclad rules have to change their 
dogma from year to year. 

But there are broad general principles which 
you will find safer than dogma. Two of those 



26 CLINICAL TALKS 

broad principles I have shown you to-day; 
asepsis, rigid asepsis, must be your sheet anchor 
in all surgical work. Physiological support, 
immobilization, compression, next after asepsis, 
are essential for the safe and prompt healing 
of the great majority of wounds. 



LECTURE III 



SIMPLE FRACTURES 



Gentlemen: Percival Pott fell down in a Lon- 
don street and broke his leg a hundred and 
thirty years ago. He got well and wrote about 
it, and since then surgeons have known more 
about fractures than they knew before. Pott's 
famous fracture marks an era in our annals. 
From that time to the present our knowledge 
has been growing more definite, until to-day, 
with x-ray plates for aid in diagnosis and the 
admirable book on treatment by our friend 
Dr. Scudder, there is small excuse for any sur- 
geon's going far astray. Yet men, even the 
expert, do go astray. Probably there is no 
class of cases presented to us which is so easy of 
misapprehension, and in which the results of 
misapplied treatment are so deplorable. We 
have no time here for a general lecture on frac- 
tures, but I will speak to you now of two or three 
simple cases and illustrate the methods of 
handling them, of making the diagnosis, and 
applying a suitable treatment. I shall speak 



28 CLINICAL TALKS 

only of closed fractures, or as they are more 
commonly called, simple fractures. 

The analogy between lesions of the soft parts 
and of bones is a close one. The processes of 
repair are not dissimilar and the rules of treat- 
ment do not diverge greatly. But our analogy 
is incomplete in one important particular. In 
the case of severed soft parts union will take 
place though the apposition be imperfect, and 
though the united structures themselves be 
dissimilar, — with a delayed result, to be sure, 
and with more or less impairment of function; 
— there we have nature, unaided, working out 
her faulty solution of the problem. But in 
the case of a broken bone, our art must be 
carefully and constantly applied, if the injured 
member is to be restored to any sort of useful- 
ness. 

Here is a boy, sixteen years old, who while 
running fell against a curbstone about an hour 
ago, and injured his forearm. You see he sup- 
ports the damaged limb with his hand and 
complains bitterly of pain half way between 
the elbow and the wrist. Let us proceed with 
our examination carefully and painlessly to him, 
so far as we can. 

In the first place the patient's clothes are 
stripped off to the waist, thus allowing of easy 
inspection — an important point. In remov- 
ing the various garments, slip off the coat sleeve 



ON MINOR SURGERY 29 

from the sound side first; then the injured arm 
can be uncovered without undue straining. 
Cut the shirt down the front and slip it off as 
you would a coat. 

Allow both his arms to hang down, and ob- 
serve any differences in them. You see that 
the affected arm hangs limp and motionless; 
the boy cannot raise it. It appears slightly 
swollen, and you may detect a slight backward 
bowing. So much for inspection. 

Then compare the two arms by measure- 
ment. You see that on the sound side the 
distance from the tip of the olecranon to the 
ulnar styloid is ten inches. On the affected 
side it is nine and one quarter inches. Obvi- 
ously there is a shortening of the bones; that 
means fracture. Is it a fracture of one or both 
bones? Of both certainly; for if the ulna alone 
were broken, the radius would act as a splint 
and maintain the length of the arm with little 
if any shortening. So you have very properly 
concluded that you have to deal with a fracture 
of both bones of the forearm, and so far you 
have caused not the slightest pain. It remains 
to locate the exact seat of the fracture. Now it 
may be necessary to hurt the patient somewhat, 
but if you proceed cautiously, he will bear it 
well. It is best to employ an assistant — two 
assistants are even better. The patient sits 
with his arm extended upon a table. One 



30 CLINICAL TALKS 

assistant supports the elbow firmly, the other 
holds steadily the lower part of the forearm, 
making gentle traction; for there is spasm 
and contraction of the bruised muscles. I now 
run my hand gently up and down the arm and 
come at once upon this area of thickening, 
about five inches above the wrist. That area 
is the seat of fracture. Grasping the arm firmly 
above and below the injury, while the assistant 
continues to make traction, I mould the bones 
into position, reducing the over-riding where 
the distal fragments have slipped over and be- 
hind the proximal. While so moulding I ex- 
perience that sensation of grating or crepitus 
of which you hear so much. While we keep up 
the traction you now see that the arm has been 
brought back to the same measurement as its 
fellow. If the spasm had been very strong and 
reduction of the fracture impossible without 
causing great pain, we should have given the 
patient an anaesthetic. 

We come now to the difficult question of 
support and immobilization, for as John Hunter 
said, ' ' The first and great requisite for the res- 
toration of injured parts is rest." Shall we em- 
ploy our cotton rollers and mill-board strips 
with elastic compression? That certainly would 
give rest to the parts, and it has at times 
been used with success in these cases. If this 
were the fracture of but one bone I should use 



ON MINOR SURGERY 31 

that dressing. As a rule, however, its very- 
elasticity renders it unsafe when we need exten- 
sion or traction to keep the bones from again 
over-riding. There are innumerable splint ma- 
terials, from plain strips of wood to moulded 
gutta percha, wood fiber, felting, and plaster 
of Paris. The first of these, known among us 
as "splint wood," and the plaster of Paris, are 
convenient and are in common use. I shall 
use splint wood in this case, as the arm will 
probably swell, and such splints can be removed 
easily and readjusted. 

There remain two other important points 
for you to consider before we apply the dressing. 
You can lay it down as a safe general rule in all 
fractures of the long bones, unless the fracture 
occurs close to the end of the bone, that the 
adjacent joints at either extremity must be 
immobilized, otherwise the play of the muscles 
would not be held in check and with the move- 
ments of the joints there would be a constant 
displacement of fragments. Moreover, with- 
out immobilizing the joints the required exten- 
sion could not be maintained. In this case we 
must fix the elbow and the wrist. 

The second point is that with fracture of both 
bones of the forearm and the possible large 
resulting calluses which sometimes form, the 
position must be such as to keep the shaft 
of the radius as far as possible from that of the 



32 CLINICAL TALKS 

ulna, else all four wounded ' bone surfaces might 
become united in a common callus, and future 
rotation be impossible. In supination, with 
the palm turned upward, the shafts are well 
apart, in semi-pronation they are somewhat 
farther apart, in extreme pronation they are 
thrown close together, and if there be extensive 
laceration of soft parts it is possible even for 
the distal fragment of the radius to become 
united with the proximal fragment of the ulna. 

In our present case I have the arm held 
firmly in semi-pronation and proceed to apply 
my splints — a simple matter after all this 
explanation. 

The splints, of light, thin wood, should be a 
quarter of an inch wider than the forearm. 
The posterior splint extends from three inches 
above the fracture to the metacarpophalangeal 
joints; the anterior splint from the same point 
on the forearm to the middle of the palm, and 
a large crescentic groove is cut out of its side to 
avoid pressure on the thenar eminence. The 
splints are carefully padded with six sheets of 
wadding, with extra small pads on the anterior 
splint to conform to the contour of the wrist. 
Then an ' ' internal angular ' ' splint of moulded 
tin is similarly prepared to support the elbow. 

While the arm is held steadily by an assist- 
ant, who stands on the patient's outer side, I 
apply these splints and fasten them firmly but 



ON MINOR SURGERY 33 

not tightly in place by four-inch adhesive straps, 
passed round one and a half times. There are 
three straps — one about the proximal end of the 
splints, one about the wrist, and one about the 
palm, embracing the posterior splint only. 
This last strap is very important, as by its firm 
pull on the posterior splint it keeps up traction. 
Then the elbow splint is applied with three 
straps — one at each end and one just below the 
bend of the elbow. The whole I cover with a 
cotton roller, snugly put on. That is a fairly 
comfortable dressing, but you must still be on 
the lookout for trouble. Keep the patient in 
sight for half an hour, and see that there is no 
return of pain before he leaves the hospital. 
Increase of pain, throbbing pain, especially if 
the fingers become swollen or blue, means that 
your splints are too tight. You must remove 
and reapply them. Then you must support 
the arm in a comfortable sling before sending 
the patient out. If he goes from the hospital 
in pain, you may be certain that he will suffer 
greatly before to-morrow, and the frequent swel- 
ling of the arm, against the immovable splints, 
will give rise to ugly skin sloughs. 

So much for this familiar dressing which you 
see applied almost daily in our clinics. But 
the after-treatment — that is not always so 
easy; it calls often for the best judgment and, 
when neglected, may lead to serious deformity. 



34 CLINICAL TALKS 

Moreover, these forearm fractures not uncom- 
monly result in non-union, and against that 
you must guard. 

One advantage of this use of open splints is 
that they are easily removed for inspection of 
the wound. I will ask this boy to return here 
daily for three days. If I find the arm pain- 
less, and the swelling not conspicuous, I shall 
then have him wait until a week from the 
accident has elapsed before I change the splints. 

Here is another patient with a similar frac- 
ture ten days old, whom I have kept to show 
you. You see that on removing the bandage 
the position of the bones appears good, the 
swelling has subsided, and the plaster straps 
are a little loose. The splints are now off, and 
a slight callus is felt over the seat of fracture. 
The skin is shrunken and pale and the elbow and 
wrist are moved with some pain and difficulty. 
Here is your opportunity, if you want to help 
the union and hasten convalescence, to do a 
piece of work usually neglected, but for which 
your patient will bless you. Call in a compe- 
tent masseur, if you can find one, and have him 
manipulate the elbow, the wrist and the tissues 
about the fracture for half an hour every day. 
The arm must be securely held on a firm cushion 
or on the padded table while the masseur is at 
work. He kneads the muscles about the 
joints, he loosens slight adhesions, he restores 



ON MINOR SURGERY 35 

the stagnant lymphatic circulation, he stimu- 
lates the circulation of the whole arm, and by 
thus improving the nutrition of the parts he 
hastens the union of the broken bones. If time, 
permitted I could tell you more about this, 
valuable measure of massage in fractures. I 
have employed it for years in such cases as 
have come under my care, and am constantly 
impressed with its advantages — in the hasten- 
ing of repair, in the early restoration of func- 
tion, perhaps best of all in the sense of well- 
being given at the time, and in the feeling of 
security and confidence so soon as the patient 
reaches the stage at which active movements 
begin to succeed these passive ones. Under 
the old-fashioned treatment the arm was like a 
prisoner confined for weeks in a dark, narrow 
cell, to emerge at the last, pale, timid, spiritless, 
broken-down, — who must wait weeks yet before 
his proper vigor returns to him. With massage 
you let in air and light upon your captive; his 
windows are thrown open daily and he is taken 
for a brisk walk, as it were, about the prison 
yard. At the end of his confinement he returns 
to the former life with his force but little 
abated and his zest sharpened for the work 
of the world. 



LECTURE IV 



LACERATED WOUNDS 



Gentlemen: The first patient I have to show 
you this morning presents a condition calling 
for the nicest judgment. 

He is a teamster, forty years old, sound and 
vigorous. Last evening while unloading his 
wagon he let fall a heavy iron bar, the end of 
which struck his calf and inflicted this ragged 
triangular wound. Some six inches of skin 
are torn up, the muscles are lacerated and the 
head of the fibula is exposed. The bleeding 
has been inconsiderable. At the time, he wrapped 
an old handkerchief about the leg, passed a 
painful night, and now comes here for treat- 
ment. 

Forty years ago, in the days of the Civil War, 
such an injury might eventually have led to 
amputation; even now it is not without its 
dangers. Septic material has undoubtedly been 
carried deeply into the leg. The iron bar 
itself was unclean, and the man's well-worn, 
sweat-soaked working trousers are far from 

36 



ON MINOR SURGERY 37 

aseptic, while the skin of the leg itself is loaded 
with organisms. 

Two courses are open to us — to clean up the 
leg and the wound, apply wet antiseptic dress- 
ings, and look for a slow healing by granulation, 
or to bring the severed skin and soft parts back 
into place and try to obtain a prompt healing 
by primary union. 

I shall adopt the latter course, and I believe 
that by the application of our two great surgi- 
cal principles — asepsis and physiological rest 
— we may look for a good result. That pleas- 
ant old Frenchman, Le Dran, in 1735, used to 
tell his classes that in such cases as this he 
always tried for a primary union, because if 
that failed through catching cold in the wound 
he could take out his stitches and look for a 
second intention. I suppose that phrase ' ' catch- 
ing cold " is as old as Hippocrates. 

Of course Le Dran's reasoning still holds 
good, though to us now such a method seems 
a half-hearted way to approach a surgical 
problem. 

We begin our proceedings by etherizing the 
patient. It is cruel as well as stupid to at- 
tempt so painful and extensive a dressing as 
this without an anaesthetic. The leg is shaved 
and thoroughly scrubbed, then the wound is 
mopped out with peroxide of hydrogen, fol- 
lowed by bichloride alcohol 1 to 3,000. Bits 



38 CLINICAL TALKS 

of torn clothing and dirt are picked out first, of 
course, and we are now ready to proceed. If 
you look carefully you see that these fragments of 
torn muscle are viable ; they bleed easily and can 
be reunited. The sewing of them properly is 
very important for two reasons — because if 
left loosely flapping no good muscle union will 
result and the leg will be just so much weak- 
ened, and because the drawing of them together 
fills up the cavity between and prevents the 
collection of blood where it would serve as a 
culture medium in that "dead space." Here 
again I cannot forbear quoting wise old Le 
Dran, who said that in a deep wound in which the 
muscles were divided obliquely, the deep stitches 
should be passed so as to run parallel with the 
muscle fibers and not obliquely, as would be 
natural in sewing up an incised wound. 

Then having closed in the deep parts, I lead 
into the bottom of the wound a single strip of 
absorbent tape or wick, placing it gently and 
loosely, that it may act as a drain and not as a 
cork. The skin is now drawn over the restored 
muscle and stitched into place with a half dozen 
silver or silkworm-gut stitches. The leg is again 
washed with bichloride alcohol and elevated in the 
air, thoroughly to drain the veins and promote 
freer circulation. Our asepsis is complete; now 
comes the second step — support and immo- 
bilization. 



ON MINOR SURGERY 39 

In this case we must bind the muscles from 
the toes to the middle of the thigh. First, I 
cover the wound with a handful of loose absor- 
bent gauze, to act as a drain and reservoir for 
the inevitable discharges, then firmly and 
snugly I apply our mill-board and wadding 
rollers. You see how securely they hold the 
leg and how the knee and ankle both are im- 
mobilized without discomfort. 

We cannot put the leg in an ordinary sling 
as we did the arm, but we can keep it elevated, 
and so add greatly to the patient's comfort. 
Of course this man must lie in bed for a few 
days. We swing a gauze hammock from a rod 
which is stretched from the headboard to the 
foot of his bed. In this hammock the whole 
leg rests, from foot to hip. That is a most 
satisfactory, comforting device. It gives us 
our required support and elevation, and as it 
swings, it allows the patient to shift himself 
about and even turn in bed without disturbing 
the wounded leg; for as the body moves the 
hammock swings, but the leg remains relatively 
at rest. 

To-morrow the wick will be removed under 
the strictest aseptic precautions; the leg will 
be bound up again, and at the end of a week I 
hope to be able to show it soundly healed. 

Ambroise Pare wrote to his petit maistre in 
1580: "M. le Prince de la Roche-sur-Yon, who 



40 CLINICAL TALKS 

dearly loved the king of Navarre, drew me aside 
and asked if the wound were mortal. I told 
him Yes, because all wounds of great joints, 
and especially contused wounds, were mortal;" 
and in the sequel the King of Navarre died. 

Five years ago, a friend of mine, while lead- 
ing a landing party on the coast of Cuba, was 
shot through the elbow by a Mauser rifle. The 
wound was properly dressed and supported, 
and in the course of a month the use of the arm 
was restored perfectly. 

Here is an Italian who got mixed up in a 
scuffle last night. He came out of it with this 
ugly, ragged cut, which has nearly severed the 
insertion of the triceps tendon and has laid 
open freely the elbow joint from behind. As 
I hold the edges of the wound apart you see the 
articulating surface of the olecranon and a bit 
of the internal condyle. Let us attempt to 
save the arm with a useful joint. 

The man is etherized, the arm carefully dis- 
infected, and while an assistant holds the 
wound open I wipe out the joint with the little 
gauze sponges dipped in bichloride alcohol and 
then douche it thoroughly with sterilized water, 
taking pains all the time not to bruise or other- 
wise injure the serosa, lest I set up an adhesive 
inflammation which might lead to anchylosis. 

Next, with fine chromicized catgut stitches, 
I sew up the rent in the capsule and unite accu- 



ON MINOR SURGERY 41 

rately the severed ends of the triceps muscle. 
In sewing up the capsule I have taken special 
pains to evert the edges, that no rough surface 
be turned into the joint to cause mechanical 
irritation. Then the skin wound is brought 
together, and covered in with gauze pads. In 
the final binding of this arm we have to meet a 
problem which differs from most of those en- 
countered in the upper extremity. We can- 
not flex the elbow and support it in a sling, for 
by so doing we should run the risk of tearing 
the freshly-sewn triceps. So the arm is put 
up in extreme extension, with our mill-board 
strips to preserve fixation and plenty of cotton 
rollers to give elasticity and comfortable, even 
compression. 

This man must not be allowed to go out with 
his arm swinging at his side. The wound is 
a serious one and demands great care for a few 
days. He will be put to bed and the arm kept 
at an angle of 45 °, either on pillows or, as I 
prefer, in our gauze hammock. 

A week ago to-day I was asked by a physi- 
cian in a neighboring town to see a patient, 
with a view to an amputation. The man was 
suffering from a wound somewhat similar to 
this last one, but in the knee joint. 

He had received his injury ten days previ- 
ously. Not realizing its gravity, he had neg- 
lected to call a physician, contenting himself 



42 CLINICAL TALKS 

with lying in bed and keeping the knee wet with 
applications of " listerine." My friend had seen 
him only a few hours before my visit. I found 
the patient to be a middle-aged, sturdy sea- 
captain. He was lying in bed and was evi- 
dently in pain. There was a punctured wound 
on the outer side of his right knee joint. The 
edges were gray and sloughy looking, and a 
thin pus could be pressed out through the 
opening. A culture from this discharge showed 
later a staphylococcus infection. The whole 
knee was red, boggy, tender, and swollen, the 
dimples on either side of the patella being oblit- 
erated, and the synovial pouch distended three 
fingers' breadths above the patella. The man's 
temperature that morning was ioo° F., and his 
pulse no; his face was flushed, appetite nil, 
and the picture that of a very sick man. There 
was present a leucocytosis of 26,000. 

I agreed with my consultant that an ampu- 
tation must be considered, but advised making 
an attempt first to save the leg. The patient 
was etherized, the leg cleaned up and the 
wound enlarged so as to admit of thorough 
exploration of the joint. The serosa was seen 
to be deeply injected, and several ounces of pus 
were evacuated, but the integrity of the joint 
apparently was not yet affected. The whole 
interior surface was carefully and laboriously 
mopped with peroxide of hydrogen and douched 



ON MINOR SURGERY 43 

with sterilized water. A counter-opening on 
the inner side of the patella was made for drain- 
age and a tape was inserted in either wound. 
Then a large absorbent pad was placed about 
the knee, the leg thoroughly wrapped and sup- 
ported after our familiar fashion — the dress- 
ing extending from the toes to the groin. The 
leg was slung in a hammock, a quarter grain 
of morphia hypodermically was administered, 
and the patient was left with careful directions 
that his bowels be kept open by salines and his 
strength supported by frequent liquid nourish- 
ment and a drink of Scotch whiskey three times 
a day. 

Of course in this case we did not look for the 
restoration of a sound, flexible knee joint. The 
best outcome to be expected was the saving of 
the leg with a stiff knee. I did not hear of that 
man again until last night, when my friend 
again asked me to see him, and to do the dress- 
ing. The picture he presented was most refresh- 
ing. Except for pallor and feebleness, all evi- 
dence of sickness had left him, and he received 
me with the comfortable assurance that he was 
well. During the week the wicks had been 
changed three times by his attendant, and I 
now removed them for good and all. On tak- 
ing off the dressing I found the leg pale and 
the skin shriveled in appearance, with the fa- 
miliar contour of the joint restored. There 



44 CLINICAL TALKS 

was slight though rather painful motion, which 
I did not encourage. The two wounds were 
granulating well. I replaced the apparatus, 
and do not expect to see the patient again. 

This was a gratifying result. I attribute it 
to the man's remarkably good general condi- 
tion, supplemented by the strict enforcement 
of our cardinal rules, — asepsis and support. 

Let us look for one moment at this other 
man — the tinsmith, whose cut hand we 
sewed up ten days ago. 

It has not been seen in the interval, though 
he has reported to assure us of his comfort and 
the absence of pain. Freed of its dressings, 
you see that the wound has healed per primam, 
as was to be expected. We shall confine the 
hand in a light bandage for five or six days 
longer and then send the man back to his work. 

I am showing you good results only, but you 
must not conclude from them that surgeons 
are wizards. Bad results, unavoidably bad 
results, come often enough, and you will see a 
plenty. For the present, we are illustrating the 
constant saying of Ambroise Pare, "I dressed 
him, and God healed him." 



LECTURE V 



COMPOUND FRACTURES 



Gentlemen: In connection with the subject of 
lacerated wounds I must say something to-day 
about compound fractures. They are no more 
than special varieties of lacerated wounds. 

These fractures were regarded with extreme 
alarm in the old days, and are still not to 
be treated cavalierly. Chelius of Heidelberg 
wrote in 1 8 2 1 that ' ' the inflammation is always 
very great and requires strict antiphlogistic 
treatment, blood-letting, leeches, cold applica- 
tions, and opium," and that mortification and 
delirium tremens may occur, especially in old 
people. " If sleep do not take place death is 
the consequence. On dissection frequently 
there is exudation on the arachnoid, pus in the 
joints and in the sheaths of the tendons." 
All of which, of course, results from the fact 
that we have to deal with a lacerated and easily 
infected wound, which involves a structure of 
low vitality. 

Our effort therefore must always be to sub- 
stitute a closed fracture for an open one, and 



45 



46 CLINICAL TALKS 

then to treat the damaged bone on the ordinary 
principles. Here again we come back to that 
matter of rigid asepsis and immobilization, the 
latter being of very great importance, for broken 
bones which are not held strictly at rest keep 
up an irritation of the wounded soft parts, 
delay healing, favor the continued outpouring 
of a sero-hemorrhagic exudate, and so provide 
a medium for the development of micro-organ- 
isms. 

The young woman whom I show you was 
jostled against a moving cart six days ago, and 
her arm, thrust between the spokes of the 
wheel, was severely mangled. On being brought 
in here shortly afterwards, it was found that 
both bones of the forearm were broken in the 
middle third and that the two upper fragments 
were protruding through a hole in the skin on 
the dorsum. The house surgeon who dressed 
the case, very properly was not content with 
mere reduction of the fracture, but with pains 
and elaboration restored the continuity of all 
the severed parts. The wound was enlarged 
by free incisions, all bleeding completely 
checked, the bone fragments placed in apposi- 
tion, the wound thoroughly douched with anti- 
septics, torn muscles and fascia sutured, the 
skin wound closed and the arm carefully dressed 
and secured in the wooden splints I have shown 
vou. 



ON MINOR SURGERY 47 

This free opening and cleaning up of com- 
pound fractures is especially important when 
the forearm is involved, for in it non-union fre- 
quently occurs, owing to the interposition of 
muscle fragments, or tendons, between the ends 
of the bones. 

In the present case the arm was bound firmly 
to the side to insure perfect rest. After recover- 
ing from ether the young woman experienced 
little pain; the next morning her temperature 
was 99 F. It never rose higher and we may 
presume fairly that the superficial wound has 
now healed satisfactorily. You see that on re- 
moving the dressings our presumption is justi- 
fied. The skin wound is soundly healed; there 
is no swelling or redness, and we are left to 
treat the case as a simple fracture. 

The next case was a much more difficult 
one, and illustrates a point which I made for 
you at our first exercise. This man is a brake- 
man, forty years old. Four months ago he 
had his left humerus broken by being crushed 
between two freight cars. The fracture was 
a compound one, but the external opening 
healed readily, and under a properly applied 
plaster of Paris dressing union of the bone was 
going on well, as we supposed. After a month, 
however, non-union was apparent, and after 
two months the condition had not improved. 
A careful investigation of the man's past his- 



48 CLINICAL TALKS 

tory then revealed the fact that some five years 
ago he had a venereal sore, followed by an in- 
guinal adenitis and a skin eruption, for which 
he submitted to about six months only of treat- 
ment. He was immediately put on to mercu- 
rials and iodides for a presumable syphilis, with 
the result that, after another month, fair union 
had been established and now we find his left 
arm as sound as its fellow. That question of 
an old syphilitic infection is never to be lost 
sight of in these cases of delayed union. The 
other more frequent general diseases which 
may complicate recovery are tuberculosis, dia- 
betes, malaria and that indefinite thing which 
we call rheumatism, for want of a better name 
and understanding of its true nature. 

Our third case was a more serious affair than 
either of the two preceding, but is interesting 
because it shows how bad may be the results 
which sometimes follow the careful conserva- 
tive surgery of to-day. 

The subject is a man of sixty who has all the 
appearance of having led a laborious life. He 
has an» obvious arterio-sclerosis, though a thor- 
ough examination of the chest and kidneys 
elicits nothing abnormal. As old John Aber- 
nethy remarked on opening his surgical lec- 
tures a hundred years ago: "Now I say that 
local disease, injury, or irritation may affect the 
whole system, conversely that disturbance of 



ON MINOR SURGERY 49 

the whole system may affect any part." That 
ancient fact is the crux on which this case turns. 

The man is a weaver. About six weeks ago 
his left hand was caught in his machine and 
severely torn at the wrist. The radius was 
fractured, the ulna dislocated, the wrist joint 
opened, the skin and other soft parts over the 
dorsum severely mangled, and he was brought 
in here with the hand hanging off, attached 
only by the skin and tendons of the front of the 
wrist. There again was the question of com- 
pleting the amputation which the machine had 
begun, or of attempting to save the hand. I 
determined on the latter seemingly hopeless 
undertaking. 

After the usual careful preparation, two 
loose fragments of the radius were removed, 
including the articulating surface, and the pro- 
truding end of the ulna was cut off, in order to 
convert the injury from a compound fracture 
and dislocation into a compound fracture, 
which would be more likely to heal than would 
the contused and lacerated joint. As a result 
of this removal of the ends of the forearm bones, 
we produced a partial resection of the joint, 
which would mean for us at best a hand with 
considerable impairment of motion. Then the 
torn tendons were secured, trimmed up and 
united, tape drainage was inserted, the skin 
wound sewn with silver wire, and the arm put 



5o CLINICAL TALKS 

up in the mill-board apparatus. The patient was 
put to bed and the limb slung in a hammock. 

The case went as badly as it could well have 
done. That night the patient's temperature 
was ioo° F., and his pulse ioo. The next morn- 
ing the temperature and pulse were 101 and 90 
respectively. The dressing was taken down, 
the skin stitches removed,- and the wound 
cleaned up, but that night the temperature had 
reached 103 and the pulse 120. The next 
day, two days from the accident, the patient's 
condition was alarming. With temperature 
at 10 2 and pulse 112, he had every appearance 
of being thoroughly septic, as it is called. Evi- 
dently the wound was an active streptococcus 
factory, pouring pyogenic organisms and their 
products into the general circulation. This 
we must conclude, although as is so often the 
fact in similar cases, cultures of the man's blood 
were negative. The patient's arm showed a 
striking picture — such a picture, fortunately, 
as you seldom see in these days. The wound 
was sloughy looking, and exuded a thin saneous 
pus. The whole forearm and hand were swol- 
len, tense, red, and shiny. The skin of the back 
of the hand was blue and necrotic looking, and 
it was evident that we had to deal with the 
inception of an acute gangrene 

Not least significant was the patient's general 
appearance. He was hectic, anxious, and rest- 



ON MINOR SURGERY 51 

less, with that almost indefinable septic look, 
with saffron skin and injected conjunctivae, 
which experience teaches us to associate with 
these alarming cases. 

Of course there was but one thing to do. 
The rotting arm was killing the man, and it 
must be taken off. I amputated it about three 
inches above the limits of the old wound, left the 
flaps wide open for the sake of more complete 
drainage, and had the satisfaction,. the next day, 
of finding him established on the road to con- 
valescence. The further story is uneventful. 

You will scarcely find a case to illustrate 
better the extreme danger of some of these 
compound fractures, and the bearing which 
the patient's state of general health may have 
on the local lesion. Here the man's premature 
old age, and the general impoverishment of his 
system, consequent upon an inefficient circu- 
lation, were the underlying and salient features. 
He could put up no fight against the overwhelm- 
ing bacterial invasion, and so capitulated only 
in time to save his life. 

In a city the place to see compound frac- 
tures is at the general hospitals. You will 
rarely see these cases in private practice. Such 
injuries occur mostly among handicraftsmen, 
day laborers, and those persons engaged in extra- 
hazardous vocations, such as railway trainmen, 
linemen, roofers, firemen, and the like; and these 



52 CLINICAL TALKS 

men when injured are commonly taken at once 
to a hospital. So, too, with any person in any 
walk of life who may be injured in a street 
accident — he is immediately hurried here by 
the zealous bystanders or police. It is fortunate 
that this is so, for in a hospital is found the 
fullest equipment to meet these emergencies, 
and a competent surgeon is' always on hand. 

The commonest and perhaps the most im- 
portant of these compound fractures are man- 
gled and lacerated hands. We see them here 
daily, and I am able to show you now a man 
suffering from such an injury. I say that these 
accidents to the hand are most important be- 
cause serious crippling or loss of the hand 
means a loss of livelihood to the victim, and to 
the surgeon each of these cases means a fresh 
problem of very great interest. Every half 
inch of finger saved and every joint restored is 
of importance. Most of all the thumb, that 
distinctive mark of a higher evolution, is to be 
preserved if possible. The thumb without the 
fingers may still adorn a stump capable of grasp- 
ing a tool and doing work, but a hand deprived 
of the thumb is a very futile member. 

This present patient is a machinist, whose 
right hand was caught between cog-wheels 
this morning. We take off the bloody wrap- 
pings and find the conditions which you see — 
all four fingers mangled but the thumb unin 



ON MINOR SURGERY 53 

jured. A flap of skin over the dorsum, with 
its pedicle towards the wrist, is torn up, dis- 
closing the second and third metacarpal bones, 
which are fractured. The whole of the fore- 
finger is mashed; the joints opened and the 
distal phalanx wanting, There is no prospect 
of saving that member, but the other fingers, 
though lacerated, may be saved, I believe. 
That hand means a study in reconstruction, and 
perhaps two hours of painstaking work at patch- 
ing and mending. Ether and asepsis are our 
first steps, and those of you who will sit down 
here with the house surgeon at his task will see 
the exhaustive care he puts into it. All bleed 
ing is checked, every torn tendon is stitched 
and replaced, bits of destroyed tissue are 
trimmed away, hopelessly comminuted bone 
fragments are removed, each finger is treated 
as a separate problem and given its appro- 
priate dressing, skin flaps are drawn up to 
cover exposed stumps and the forefinger is 
amputated at the middle of the first phalanx. 
When all this is accomplished satisfactorily 
the hand is spread out upon a well-padded 
splint, with dry gauzes about and between the 
fingers, and the limb to the elbow is put up in 
an abundant elastic-compression dressing. It 
is very important in this case, as in the case of 
the man with a cut palm, whom I showed you 
at our first exercise, that the muscles of the 



54 CLINICAL TALKS 

forearm and hand be immobilized absolutely. 
We must have no dragging on these freshly 
united tendons and delicate, new forming tissues. 

Then the arm is supported carefully in a 
sling or held high on the chest in a Velpeau 
bandage. If all goes well the patient may ex- 
pect the use of his hand by the end of two 
months, but we can give him no such positive 
assurance. Skin flaps may lose their vitality; 
bones may suffer from osteo-myelitis and be- 
come necrotic; tendons may slough; sinuses 
leading to deep-seated inflammations may per- 
sist for weeks, and many and various minor, 
secondary operations may be necessary before 
we are through with this case. But the great 
preliminary care is worth the patient's while, 
and ours, for all that. With it we can promise 
him a useful hand; without it he would have 
to expect a crippled, helpless claw. 

In connection with this subject of lacerated 
hands, I must warn you that you will find the 
treatment of lacerated feet a still more difficult 
matter. It is not because there is anything 
peculiar in the structure of the feet, but because, 
owing to their dependent position, their circu- 
lation, except in the case of the young and 
vigorous, is not so good as is that of the hands. 
That you must always bear in mind if you 
would avoid trouble for which you might justly 
be held to blame. 



ON MINOR SURGERY 55 

Take two similar cases — a man with a 
jammed thumb and a man with a jammed toe. 
You dress up the former and send him home, 
to find in the course of a couple of weeks that 
he is quite well. You dress the man with the 
jammed toe and send him off about his busi- 
ness, and what do you find? By the end of 
two weeks, in spite of oversight, the toe is far 
from healed: it is red, tender, and slightly sep- 
tic; the whole foot is swollen and tender, and 
very likely there is a bit of necrotic phalanx to 
be felt. This untoward result is due to no lack 
of aseptic precautions on your part, but to the 
fact that you have failed to observe our second 
cardinal principle — support. You cannot 
safely send these patients out to knock about 
the streets. Either they must be put to bed 
with the leg elevated — the best thing by far — ■ 
or they must be instructed to bear no weight 
on the foot and to keep it up on a chair or sofa 
except when necessarily in use. The point 
sounds like a small one, but it is salient. 

So much for compound fractures — perhaps 
the most important division of traumatic sur- 
gery. We have but skirted the border of a 
great subject, but sufficiently near, I trust, to 
show that here, as in the lesser lesions con- 
sidered, the same broad, inevitable principles 
constantly must be applied. 



LECTURE VI 

GRANULATING WOUNDS AND VARICOSE ULCERS 

Gentlemen : There exists in the minds of 
students, and often of graduates as well, a 
confusion regarding ulcers and granulating 
wounds. It is a natural confusion, for the 
two conditions overlap and run into each 
other. An ulcer may be described as a super- 
ficial solution in continuity, which shows no 
tendency to heal; a granulating wound, as a 
solution in continuity, which shows a tendency 
to heal. Of course such a definition is a very 
general one, but it will answer our present pur- 
poses. You may see many examples of both 
lesions in this clinic, and you will find it diffi- 
cult in some cases to decide with which you are 
dealing. 

Ordinarily, however, there is no question 
when you are dealing with a granulating 
wound. You will see the red velvety granu- 
lations shrinking in area steadily, with little 
projections of new skin shooting in, and the 
process of repair so constant and inevitable 

56 



ON MINOR SURGERY 57 

that you can appreciate the changes from day 
to day. 

In regard to such a healthy granulating 
wound there are two questions which the stu- 
dent is always asking and about which he 
seems to feel that he gets very little light. 
With what applications shall it be treated, 
and how often shall the dressing be changed? 

Ordinarily the answer to that first question 
is a very simple one when the wound is in a 
healthy individual. Take, for instance, the case 
of this woman. Her breast was removed for 
sarcoma some three weeks ago. The skin flaps 
were not drawn tightly together at one point, 
with the result that she has on the front of 
the chest, as you see, a superficial open wound 
about the size of a silver dollar. It is clean, 
flat, bright crimson, and does not bleed easily. 
It will heal over in a few days, no matter how 
you treat it, provided only, and this is impor- 
tant, provided you keep it clean. You can wash 
it with corrosive alcohol, or creolin, put on a 
gauze cocoon, and leave it for three or four 
days. When she comes in again the pad will 
be found moistened with pus, but the wound 
clean, and smaller than to-day. Such wounds 
as this require no special care. 

On the other hand, take this case of a granu- 
lating wound on the back of the neck of this 
man. The patient is fifty years old and has 



58 CLINICAL TALKS 

two per cent of sugar in his urine, for which 
he is under treatment. Two weeks ago he 
came in here and showed us on the back of his 
neck a carbuncle the size of an English walnut. 
I excised cleanly the carbuncle, and so stopped 
the process. There has been no return of the 
active local infection, but the wound has not 
healed readily. The raw surface, as large as 
the top of an egg cup, is still nearly as it was 
two weeks ago. The granulations are dark 
purple, soft, spongy, and bleed easily when 
handled. About the edges they overlap in 
fringes. That overlapping we call exuberant 
granulations; it is a perfectly harmless condi- 
tion and is easily remedied. That is the con- 
dition known to the laity as " proud flesh," and 
is always referred to by them with horror — 
just why is not clear. 

There are various methods of treating such 
granulations, but all methods come down to 
this, that the granulations must be trimmed 
down and the wound stimulated into proper 
activity so that it shall have the vigorous, 
healthy appearance which we saw in the case 
of the woman. With the scissors I cut off 
these redundancies, — they are absolutely in- 
sensitive, — and after checking the oozing by 
sponge pressure, I wipe over the whole wound 
with the stick of silver nitrate. Then a dry 
gauze dressing is applied. Every other day 



ON MINOR SURGERY 59 

the man will return, and we hope soon to see 
the wound closing in. Another excellent 
method of treating this wound, after trimming 
the granulations, is to dust it thickly with some 
simple drying powder, such as dermatol or 
aristol. But after all, what you must bear in 
mind is that the wound is to be kept clean and 
the granulations frequently trimmed down. 
Our familiar supporting bandage must never 
be omitted, for the pressure it exercises helps 
the circulation in the parts and prevents passive 
congestion and stagnation. 

We are fortunate to have another patient 
here who presents a third type of granulating 
wound. He is a boy who received a severe 
kick on the shin about a month ago. The 
perisoteum and bone were not injured, but he 
showed us a superficial wound, long and nar- 
row, as though you had torn up the skin for a 
distance of five inches with your finger nail. 
Three weeks ago this long, narrow wound, in 
the apparently healthy lad, began to be lined 
with the small, flat, dull, red granulations 
which you see, and thus it has remained. It 
refuses to heal. It has been scarified, curetted, 
and wiped frequently with the caustic, but 
without avail. We are now planning to have 
the lad get out into the country to see what 
out-of-doors life will do for him. Meantime 
I shall dress the wound daily with a stimulating 



6o CLINICAL TALKS 

lotion on gauze and bandage the leg from toes 
to mid-thigh. 

In such cases you will find diluted tincture 
of myrrh, one part in twenty of water, or pure 
balsam of copaiba, to be excellent. I have 
always been pleased, too, with the action of 
Gamgee's favorite application: Borax, i part; 
compound tincture of lavender, 8 parts; glycer- 
ine, 4 parts; water, 24 parts. 

Such, briefly, are some of the methods of 
treating these open wounds. You will find 
in the books and be told by doctors of innumer- 
able other lotions, ointments, and applications. 
Many of them doubtless are useful, certainly 
most of them are harmless; but, after all, what 
you have to remember is to keep the wound 
clean and give nature a chance. 

In this connection I am prompted to give 
you a word of advice. You will come to find 
as undergraduates, and later as graduates, 
that there is a common tendency among certain 
men to sneer at measures and methods with 
which they are unfamiliar. Against such men 
be on your guard. They are almost as danger- 
ous in their way as are the credulous igno- 
rant. Their opinions are not founded on 
reason, but on sloth and indifference, and a 
certain tired skepticism born of sad experi- 
ence. But theirs is not the truly scientific 
spirit which waits patiently for proofs. The 



ON MINOR SURGERY 61 

unreasoning sceptics are prone to translate an 
attitude of legitimate, cautious doubt into one 
of bumptious cynicism. 

Now let me bring before you another class 
of cases, varicose ulcers, allied to granulating 
wounds, cases which are a weariness often to 
students and dressers, for by long continuance 
they become an opprobrium to these clinics. 
Yet they should not be a bore. These ulcers 
are very grievous afflictions to. their victims, 
they belong to a very interesting class of path- 
ological processes, and they heal under proper 
treatment. 

For hundreds of years surgeons have talked 
and written about varicose ulcers, and the opin- 
ions of the best surgeons regarding their nature 
and treatment have always been correct, yet 
even to-day you sometimes see the cases drag 
on an interminable course, submitted to a 
treatment which is amazing and discourag- 
ing. 

You may usually tell a varicose ulcer at a 
glance. It is on the shin, below the middle of 
the leg; above and about it are enlarged super- 
ficial veins, and commonly the leg is swollen 
more or less. In few lesions is the cause of the 
trouble as obvious as in these ulcers. Know- 
ing the cause, you must remedy that, and in so 
doing attack the disease at its source. These 
ulcers are due to varicose veins, so you must 



62 CLINICAL TALKS 

cure the varicose veins, or at least you must 
support and relieve them. 

This is such a transparent truism that it 
seems as though it should be apparent to the 
meanest intellect, yet wise men are seen to pass 
it by. Think for a moment of what the process 
is. First, there arises the dilatation of the 
veins, a condition lasting perhaps for years; 
gradually as the walls of the veins become 
thinned and inelastic and their valves incom- 
petent, a condition of stasis results. A thin 
serum oozes out into the surrounding tissues 
and causes the oedematous swelling. At the 
same time there is an exudation of red blood 
corpuscles, which produce an extensive pig- 
mentation of the skin, associated not infre- 
quently with an eczema. As a result of all 
this the nutrition of the leg is greatly impaired, 
and the ideal conditions favoring an inflamma- 
tory process with destruction of tissue are 
present. Sometimes as a result of throm- 
bosis of the veins and malnutrition of the sur- 
rounding parts, a phlebitis or a periphlebitis 
is seen; there may even be rupture of a vein 
with serious hemorrhage; but more commonly, 
as a result of some slight blow, or even scratch, 
a superficial skin lesion is caused. This refuses 
to heal in the sodden tissues, bacteria rush in, 
and a destructive ulcer is formed. 

It is for this ulcer that the victim seeks advice 



ON MINOR SURGERY 63 

at last. He seeks advice, and I regret to say 
that he sometimes is given plasters and washes, 
ostensibly for the eczema, I suppose. With 
your knowledge of the cause of his trouble 
you will say that such treatment is preposter- 
ous. It is preposterous, but you will see more 
than one patient so treated hitherto, come 
despairingly into this clinic. 

Now let me show you one of these unfortu- 
nate patients. He is a man of forty-five; a day 
laborer; a man who stands constantly on his 
legs. The pain of his disease has disabled him 
utterly. You observe, in the first place, the 
great size of his calves and feet. He is not a 
large man; he weighs perhaps a hundred and 
sixty-five pounds, but his right leg, which is 
the seat of the ulcer, measures twenty inches. 
The whole leg below the knee is of a dark red- 
dish-brown color, mottled and shiny. There 
the veins are disguised, but behind the knee 
in the popliteal space, and along the course of 
the internal saphenus you see the veins stand- 
ing out in great bunches. Over the front of 
the shin and spreading back into the calf is 
this irregular ugly ulcer, as large as your out- 
spread hand. Its edges are indurated and 
elevated, and it is lined with sloughy, dull red, 
flabby granulations. As the man says truly, it 
is a very sore leg. 

I have had the patient lie down on the ex- 



64 CLINICAL TALKS 

amining table for half an hour, with his leg 
supported at an angle of forty-five degrees. 
That has demonstrated two things. It has 
given us an idea of the extent of the swelling, 
for now we find the calf to measure but sixteen 
and one-half inches in circumference, — a 
shrinkage of three and one-half inches, — and it 
has given us an important clue as to treatment. 
Indeed, it has brought us back to our first 
principles, and shown us the importance of 
elevation and support. For let me tell you 
that the method by which most quickly to 
secure a healing would be to put the man to 
bed, to bandage properly the leg and swing it 
in a hammock. Thus the veins would be kept 
constantly emptied by the action of gravity; 
the circulation would be quickened and the 
nutrition re-established; the exudate would 
be absorbed in a few days and the ulcer would 
be converted into a granulating wound. 

For various reasons such an admirable 
method of treatment may not be instituted in 
this case, so we must adopt the next best 
method, and on the whole it is the one most 
practicable in such cases. 

In the first place, when there is any con- 
siderable oedema present, I always order the 
half hour of elevation. Thus we find that we 
have to deal with a leg of a more nearly normal 
size, with oedema diminished and veins emptied 



ON MINOR SURGERY 65 

of their accumulations. Next, to clean up the 
sloughy ulcer with its indurated border, I 
apply a gauze pad, wrung out of pure glycer- 
ine, overlapping the edges. The glycerine 
acts to draw out the serum from the tissues 
and rapidly softens the indurations. If you 
choose you may etherize the patient and curette 
the ulcer and its edges, but this rarely is neces- 
sary. Then from toes to mid-thigh I apply 
firmly, snugly, and with uniform elastic com- 
pression our wadding rollers of many thick- 
nesses and a cotton bandage. 

Now, whatever position the patient assumes, 
the veins cannot again become distended, the 
leg cannot swell, and the nutrition of the parts 
cannot seriously be disturbed. The patient 
will be directed to keep as quiet as possible 
for three or four days and to have his leg up 
on a chair most of the time, but within the week 
he will go back to work in some degree of com- 
fort. To-morrow he will return to have the 
glycerine pad removed and the bandages 
reapplied. That his condition will then be 
satisfactory I hope to show you. 

Meantime look at this second man, who is 
suffering from a similar ulcer and has been 
under treatment since the day before yester- 
day. He was dressed with our glycerine pad 
and supporting bandage, which has been once 
renewed. You see now a condition very differ- 



66 CLINICAL TALKS 

ent from that of our control patient. The leg 
is still swollen and oedematous, but not markedly 
so. The veins are inconspicuous, and the ulcer 
itself, instead of being indolent and sloughly 
looking, is lined with red and fairly healthy gran- 
ulations ; in other words, it is taking on the 
characteristics of a granulating wound. As for 
further treatment, the important thing is to 
continue our support, without which the lesion 
would quickly relapse into an ugly ulcer. To 
the granulations I shall apply sterilized absorb- 
ent gauze. Nothing else is needed, and by 
our continuing in this course I hope to show 
you, within three weeks, the wound nearly 
healed and the man going about in normal, 
comfortable fashion. 



LECTURE VII 

FELON, WHITLOW, PARONYCHIA, PALMAR 

ABSCESS 

Gentlemen: You will find it hard to define 
the first three words which give a title to this 
exercise. Felon and whitlow have no proper 
etymological reason for existence; paronychia 
is derived obviously from Uapd, around, and 
6 vuz, nail; palmar abscess is self-evident. 

I am making this seemingly needless talk 
about definitions because no two surgeons will 
be found to agree about the meaning of those 
first three words, and even the medical diction- 
aries are at loggerheads. 

Felon means one guilty of felony, a wicked, 
cruel person, hence the word has been applied 
to a cruel infection. Whitlow means literally 
a white flame; " a painful inflammation tending 
to suppurate, in the fingers or toes." 1 That 
seems a fairly good definition. Very many 
surgeons regard whitlow as identical with felon; 
I do so myself, and as I find no great authority 
or even well-established custom to oppose me 

1 Chambers' Etymological Dictionary. 
67 



68 CLINICAL TALKS 



I shall continue to do so. Remember, then, that 
for us whitlow and felon are interchangeable 
terms. 

But paronychia — there is our rock of 
offense, for fully half the authorities make it 
identical with whitlow and felon. 1 So we are 
left to follow our own fancies, and I have taken 
the liberty of following mine so far as definitely 
to contrive two definitions which I believe to 
be descriptive, convenient, and fairly accurate: 

As whitlow is felon, and the latter word is in 
more common use, I shall drop the term " whit- 
low." 

A felon is an acute infection of the finger 
(or toe), progressive, with a tendency to involve 
the bone. 

A paronychia is an acute infection of the 
finger (or toe), progressive, situated near the 
nail, which it tends to involve. 

Bear in mind that paronychia may spread 
further and involve the whole finger — in 
which case it should more properly be called a 
felon. And bear in mind also that the great 
majority of felons are situated over the terminal 
phalanx. 

1 Foster, Dunglison, Keating, Gould, and Duane group felon, 
whitlow, and paronychia under one head and call the hybrid 
affection " peri phalangeal abscess." The Century Dictionary: 
"Felon, an acute and painful inflammation of the deeper tissues 
of the finger and toe, especially of the distal phalanx; generally 
seated near the nail." 



ON MINOR SURGERY 69 

This is only a beginning of the controversy. 
We could go on for an hour juggling terms and 
disputing as to what does or what does not 
constitute felon. 

Conceive, then, of felon as an acute, progres- 
sive infection, situated anywhere on the ringer. 
It may be superficial, it may be deep, it may 
be both superficial and deep. Take that last 
conception as an example of a common form 
of felon and examine the finger of this woman. 

One week ago, as she tells us, she pricked her 
finger with a carpet tack. The little wound 
healed apparently, but after three days the 
end of the finger became red and the skin over 
the pulp elevated, somewhat in the form of an 
ordinary blister. But there was pain and 
there is pain now — throbbing, wearing pain. 
I tie a rubber tourniquet about the base of the 
finger and inject a few drops of two per cent 
cocaine along the course of each lateral nerve. 
Then with the scissors I trim off the blister. 
That leaves us with a red, mottled surface about 
the size of a silver dime. It looks like a gran- 
ulating area. All the sero-pus contained in 
the blister has been evacuated, and you would 
suppose that here was an end of the affair. If 
now I take the finger in my hand and gently 
squeeze it you see a minute drop of pus exude 
slowly from a point in the granulations. That 
means that there is a little track connecting 



70 CLINICAL TALKS 

the superficial cavity we have opened with a 
deeper cavity. This felon is a compound 
affair, with two pus chambers in tiers, one above 
the other. They are connected by the minute 
channel which was perhaps the original track 
of the carpet tack or maybe was caused by the 
inflammatory action itself. 

This form of felon with its two chambers has 
been felicitously termed a "shirt-stud abscess." 
There may be two or more connecting channels, 
but the name is just as good. So, when you 
open a superficial felon, remember that a felon 
is progressive, and search for that second cham- 
ber. Now I open the deeper pocket, of course, 
and find myself on the periosteum. I clean 
out the little cavity; wipe it thoroughly with 
peroxide of hydrogen, lay in it gently a bit of 
absorbent tape, wrap the finger in a hot creolin 
poultice, bandage the hand and forearm with 
elastic compression, and suspend them in a 
sling. 

In this place let me say one word about poul- 
tices. They have been used from time imme- 
morial for the comfort they bring to the affected 
part. Their action is to stimulate the super- 
ficial circulation, and thus, by relieving con- 
gestion, to check inflammatory action and allay 
pain. Such a use of poultices is as comforting 
to-day as ever it was. 

A poultice must supply heat and moisture; 



ON MINOR SURGERY 71 

deprived of either it is no longer a poultice. 
The materials of which poultices have been 
made are many, but mostly surgeons have tried 
to employ some vehicle which would retain 
heat. Such a vehicle is found in Indian meal, 
flaxseed and the various cereals. They remain 
moist and warm for a long time, but they are 
beautiful culture media. For a vigorous in- 
fection-spreading agent, recommend me to the 
old-fashioned bread and milk poultice. 

With Listerism there came in the so-called 
antiseptic poultice. As commonly used it is 
not antiseptic. The best that can be said of it 
in that regard is that it is aseptic. When 
properly prepared it is a useful dressing, because 
it is sterile and because by supplying heat and 
moisture it stimulates the reparative processes. 
Then, too, it is easily applied. 

So you see that in the use of the properly 
constructed and applied poultice we return 
again to our first principles — we support the 
part and we stimulate and equalize the circu- 
lation. 

That form of antiseptic poultice which I pre- 
fer is made of sheet wadding pads wrapped in 
absorbent gauze and covered with some water- 
proof material like oiled silk or parchment 
paper. The pads are wrung out of a hot creolin 
solution, one in two hundred. You may use 
bichloride or boric acid, but carbolic acid never. 



72 CLINICAL TALKS 

The poultices should do much more than cover 
the affected region only. If the whole finger 
is involved, wrap the hand; if the hand is in- 
volved, include the forearm in the poultice. 
Thus you will quiet the adjacent muscles and 
protect the efferent lymphatics. It is well 
also to put on a light splint outside of the poul- 
tice for more perfect immobilization. 

Then as to the drainage of these abscesses — 
gauze wicking is usually sufficient. Do not 
pack the cut with gauze. That will cork up 
the pus. Gauze packing is never used except 
to check hemorrhage. To drain, lay gently 
into the cut one or two wicks or tapes. These 
will carry off by capillarity the secretions and, 
being interposed between the cut edges, will 
prevent a superficial gluing together of the 
skin wound and a consequent pocketing and 
burrowing of pus in the deeper parts. 

To demonstrate further the treatment of 
felons let me show you a second case. This 
man has been aware of a throbbing pain, in- 
creasing in severity, for the past four days, 
over the middle phalanx of his ring finger. 
The primary cause of the trouble is unknown 
to him. You will observe that the whole 
finger is hot and swollen, and on compressing 
between your thumb and finger the lateral 
vessels on either side of his finger you plainly 
feel them throbbing. That is a distinctive and 



ON MINOR SURGERY 73 

interesting point in the diagnosis of localized 
inflammations of this type. You will not dis- 
cover that pulse in the case of sprains or rheu- 
matoid affections. This man's finger is not 
only swollen throughout, but its palmar skin 
is reddened, elevated, and excessively tender. 
Feel carefully in his axilla, and you detect an 
enlarged and painful gland. His body tem- 
perature is not elevated, his pulse is not rapid, 
nor is there a noteworthy leucocytosis, — the 
white count being 9,000; but he is tired from 
loss of sleep and weary with the constant pain. 
On carrying my knife deeply down through the 
skin and laying bare the tendon sheath, I give 
vent at first to an abundant bloody oozing, 
which is good. Then there follow half a dozen 
drops of pus, in which you will probably find 
streptococci in pure culture. If, now, I content 
myself with this cut and apply my dressing, 
to-morrow may show us the superficial parts 
mostly glued together. That is a condition 
we do not want, for the wound must be made 
to heal by granulation from the bottom. To 
favor such healing, trim off the skin edges so 
that they cannot readily be brought together 
— a simple and very useful manoeuvre. Now 
we apply the poultice, light splint, bandage, and 
sling. 

Properly the poultice should be changed 
twice a day at least, and by the fourth day we 



74 CLINICAL TALKS 

should begin to see a clean, granulating wound. 
The man will have pain to-night probably, and 
may need a small dose of morphia. A certain 
amount of pain nearly always follows a cocaine 
operation on a felon, but by to-morrow he 
should be in comfort. 

These two cases have been very simple ones, 
but all felons are by no means so easy of treat- 
ment. The pus burrows; tendons, bones and 
joints are involved; slashing incisions and am- 
putations may be necessary, and at the best 
some impairment of function is very apt to 
ensue. Such results you shall see daily in this 
clinic. The therapeutic measures to be applied 
differ in degree only from those you have seen 
this morning. Pus is to be sought out, drain- 
age is to be maintained, asepsis and support 
are vigorously to be enforced, pain is to be 
relieved and, always, the general condition of 
the patient is to be considered and strength- 
ened so far as well may be. 

You must look now at this third patient, 
who very conveniently presents us with an 
example of paronychia. In the limited sense 
in which we use the term, " paronychia" is the 
common nursery "run-round." This child, 
who brings it for our inspection, pulled a hang- 
nail a few days ago until she drew blood, and 
so infection entered in. Day before yesterday 
the skin about the base of the nail was reddened 



ON MINOR SURGERY 75 

and painful, forming a crescentic swelling. To- 
day there is pus obviously present, for it shows 
creamy through the thin pellicle. 

There is a common way, a common but wrong 
way, of opening these little abscesses. That 
wrong way is to cocainize the finger and draw 
the knife in a semi-circle through the skin about 
the base of the nail. So you will evacuate the 
pus, but you will have left an ugly sore, with 
the underlying nail at the bottom, to granulate 
slowly up. 

Here is a better way. I lay this narrow- 
bladed knife, flat upon the nail with the knife 
point against the inflamed skin, and by a little- 
gentle prying, which should be painless, I insert 
it along the skin edge and the base of the abscess, 
I withdraw the point, when you see it followed 
by a jet of pus. By a little manipulation the 
cavity is now evacuated, and a poultice is ap- 
plied. Unless the nail and matrix have be- 
come involved in the inflammation, sound 
healing should now be a matter of two or three 
days only. 

That was the simplest form of paronychia. 
If you carry away with you to-day no other infor- 
mation than of the little trick of opening it 
along the nail, your hour has not been wasted. 

As in the discussion of felons, so here, I have 
scarcely more than touched upon the subject. 
This process may rapidly invade the finger. It 



76 CLINICAL TALKS 

may attack and destroy nail and matrix, and 
involve periosteum, bone, joint, and tendon. 
There is no limit to its possible ravages, but for 
the avoidance of confusion, as I told you at the 
first, when the inflammation has passed beyond 
the region of the nail, I prefer to speak of it as 
felon and not as paronychia. 

Palmar abscess is the third subject to be 
considered to-day. To it felon and paronychia 
naturally and inevitably lead. It is a lesion 
of great interest, — in its pathology, its treat- 
ment, and its capacity for far-reaching damage. 
In it the infection usually starts in the palm, 
but it may begin in one of the fingers and spread 
to the palm. 

The methods of infection are therefore various, 
but perhaps the commonest method is that 
presented by the hard-working man whom I 
show you. He is a gardener. His hand bears 
heavy callosities, which have become so hard 
as to press upon and irritate the underlying 
soft structures. This bruising has caused a 
considerable blister, which has become infected 
from the overlying skin, and in turn has passed 
on its irritating properties to the deeper parts. 

As you look at the hand it appears every- 
where swollen — back as well as front. That 
puffy, reddened dorsum is swollen from oedema. 
If you were to cut into it, you would draw only 
serum and blood. But the palm shows a condi- 



ON MINOR SURGERY 77 

tion quite different. It is not so greatly dis- 
tended in appearance as is the dorsum, for its 
deep structures, bound down by the dense 
palmar fascia, cannot greatly swell. The pain 
is there, however; and it is all the more severe 
because the fascia does so limit the swelling. 
In order to escape without our aid the pus must 
burrow up under the annular ligament, into the 
forearm, and that is what we fear. So you see 
the palm of the hand to be tense, brawny, but 
not greatly swollen. It is exquisitely sensitive 
to pressure. The pus must be let out quickly, 
and here again we are presented with a problem 
which is rendered interesting by reason of ana- 
tomical complications. No other region of the 
body contains so many and such diverse struct- 
ures compressed into so small an area. There 
is here a labyrinth of tendons, nerves, vessels, 
and fascise — to say nothing of tendon sheaths, 
small muscles, and bones. All these structures 
are essential to the proper use of the hand — 
that wonderful piece of mechanism. We cannot 
go roughly slashing into it without crippling it, 
yet to get out the pus we must in a fashion 
slash. 

It used to be taught as a safe rule, and those 
who so taught were in the main correct, that 
when cutting into the palm you should make 
your incisions short, multiple, and parallel to 
the bones, thus avoiding, so far as possible, the 



78 CLINICAL TALKS 

delicate structures of the hand. That plan is 
not a bad plan — indeed, it is the one commonly 
followed still, but it has this disadvantage, that 
through these straight incisions the pus is sought 
somewhat blindly and with difficulty, and that 
the incisions tend to early closure, thus damming 
in the discharges and necessitating a second 
operation often. Moreover, such wounds heal 
with disabling scars, which are bound closely 
to the underlying parts and seriously limit mo- 
tion. 

My colleague, Dr. Brooks, has devised an 
incision which I prefer. The patient is now 
etherized. While his hand is held firmly out- 
spread I outline a semi-circular flap which in- 
cludes the whole of the palm practically. I enter 
the knife over the second metacarpo-phalangeal 
joint, as you see, and after sweeping round the 
palm I bring it out at the base of the thenar emi- 
nence; in other words, the flap is to be turned 
back on the thumb as a pivot. Rapidly dissect- 
ing away the skin, I have now exposed completely 
the palmar fascia. You see a little pus oozing 
through it at these three openings. I now en- 
large the openings with a blunt scissors and 
rapidly, without damage to structure, follow up 
and clean out all the cavities. You see I have 
had to deal with a really beautiful and well- 
exposed dissection of the palm, I have avoided 
easily the important arteries, nerves and ten- 



ON MINOR SURGERY 79 

dons, for I have seen them; and I have 
searched out the burrowing pus far more thor- 
oughly than was possible by the old blind 
method. Now I disinfect carefully the whole 
hand. 

How about drainage and the after-treatment? 

Wicks are led out from all the pockets; a thin 
layer of gauze is spread over the whole exposed 
surface and the skin flap is laid back over the 
gauze. In the subsequent dressings, when neces- 
sary, the skin flap may again be turned aside 
and the depths of the wound may again easily 
be explored. Judging by experience, we should 
find the inflammation subsiding in a day or two, 
when the wicks gradually will be removed. By 
the end of a week the palm and the under surface 
of the flap will be covered with granulations. 
Then, if all looks clean and sound, we shall stitch 
the skin back into place and look for a rapid 
healing by a delayed first intention. To facili- 
tate the sewing back of the flap we usually pass 
these so-called provisional stitches at the time 
of the original operation. When the time comes 
they will be tied. 

For the first four or five days it is well to 
dress the hand and forearm in a large creolin 
poultice with a splint, but this may be abandoned 
soon for the gauze dressing with elastic com- 
pression and elevation. 

You will be surprised to see how useful and 



80 CLINICAL TALKS 

comely a hand will result from all this. The 
scar will be there, of course, but it will not be 
especially troublesome, and the function of the 
hand will generally be much better than was 
the case when multiple linear incisions were 
used. 

Again, let me warn you, in closing, that in 
spite of what I have said of your flap at the 
thenar eminence you must never operate by 
rule of thumb. Broadly this operation is a good 
operation, but diverse conditions will present 
themselves. No two cases are alike, and while 
you must strive always to observe general 
principles, you must apply also a broader com- 
mon sense. 



LECTURE VIII 

BOIIS, CARBUNCLES 

Gentlemen: The treatment of boils may seem 
to you a very minor part of Minor Surgery, yet 
there are few curable conditions more trouble- 
some than furunculosis. 

Last winter there came to see me a man who 
is the chief of police in a neighboring town. He 
had upon the back of his neck two boils and the 
scars of half-a-dozen others. For four months 
he had been suffering from these pests, — in 
constant discomfort with a sore and painful 
neck; his sleep broken, his appetite impaired, 
and his health becoming undermined. On 
inquiry I learned that he had gone ten years 
without a day's vacation, and that for six months 
before the appearance of his boils he had been 
feeling run down and debilitated from that con- 
dition of faulty metabolism which we call 
muscular rheumatism. 

I gave him a simple cleansing wash for the 
neck and a course of aperient waters. I en- 
joined a two weeks' vacation and the follow- 
ing tonic: sulphate of iron 5ii, sulphate of 

81 



82 CLINICAL TALKS 

magnesia 5vi, dilute sulphuric acid 5vi, syrup 
of ginger 5iv, water Six, — a combination 
which I borrowed from Dr. L. D. Bulkley, 
and have found very useful in such conditions. 
The dose is one teasponful in water after meals. 
To the boils I applied merely a soft protective 
cotton dressing. Ten days later the man 
wrote to me that his boils had disappeared and 
that he was feeling well. 

That case illustrates one of the most impor- 
tant points I have to make for you in this con- 
nection. It is the point I have so often made 
for you before. You must regard your patient's 
general condition. And boils are usually a 
manifestation of a general condition. They 
indicate some form of malnutrition aud must 
be treated on that basis. 

Billings' Dictionary defines a boil as "a pain- 
ful conical or rounded swelling of the skin, due 
to inflammation about a hair follicle, a Mei- 
bomian gland, or a sweat gland." That is a 
fair enough definition, and if you will turn to 
page 172 of your Warren's " Surgical Pathology" 
you will find the nature of the process ex- 
haustively described. The point of it all, so 
far as the clinician is concerned, is that the 
organisms normally present in the skin gain 
lodgment in some of the glands or ducts and 
then multiply. The active development of 
these colonies of bacteria produces small areas 



ON MINOR SURGERY S3 

of connective tissue necrosis. This necrotic 
portion acts as a foreign body, and nature pro- 
ceeds to throw it off as a ''core." The process 
of throwing it off gives rise to further inflam- 
mation, with the resulting pus formation and 
swelling. After the core is thrown off there 
remains a little pit, which must heal by granu- 
lation. So, you see, there are three stages 
in the life history of a boil, and each stage 
demands its appropriate treatment. There 
is the first stage, when we see only a small 
superficial pustule; the second stage, when we 
see a much larger mass — elevated, indurated, 
and painful, containing its core; and the third 
stage of a craterlike but subsiding swelling. 

Most commonly a patient comes to you with 
a well-developed boil in the second stage and, 
in the neighborhood, two or three incipient 
boils or pustules. If the case is a chronic one, 
make up your mind about the patient's general 
condition, especially as regards diabetes and 
rheumatism. 

This young man before us is a good example 
of what I am describing. He is a night watch- 
man, whose daytime sleep is disturbed. He 
is given to rather excessive whiskey drinking, 
and is feeling pretty well done up. He has a 
poor appetite, constipation, a furred tongue, 
and is a striking type of the tired man who is 
burning the candle at both ends. I need not 



84 CLINICAL TALKS 

trouble you with details of general treatment 
in his case except to say that I shall stop his 
liquor, and give him a course of Carlsbad salts, 
with five grains of Blaud's pill before his meals. 
Look now at the back of his neck. Here on 
the right side is a conical swelling the size of a 
silver "quarter." It is reddened at the center, 
where it is beginning to break down and soften, 
but everywhere else it is indurated. It is very 
tender to the touch, painful on pressure, and 
he says it "feels sore all round." To the left 
of it are these three little pustules, with red- 
dened areolae, each about half the size of your 
little finger nail. In the first place, as regards 
these incipient boils, let me tell you with much 
assurance that they may be aborted. The 
old-fashioned method was to poultice the back 
of the neck and bring the whole crop to a head. 
Don't do it. There are scoffers who will tell 
you that boils cannot be aborted. I doubt if 
they have tried faithfully any method. Here 
are two methods. You may prick the little 
pustule and wipe out the minute cavity with 
a probe dipped in pure carbolic acid. That 
often will suffice, but I have not found it so 
successful as the hypodermic injection of very 
small quantities of some strong antiseptic. 

In the first place I cleanse this neck with 
soap and water and alcohol. Then I inject 
five or six minims of cocaine, in four per cent 



ON MINOR SURGERY 85 

solution, under the infected areas. Now into 
this anaesthetized zone, along the cocaine 
track, I inject, under each pustule, two minims 
of pure styron, — an ancient but efficient bal- 
samic antiseptic. I prefer it to carbolic acid, 
because more thoroughly it permeates the 
affected tissues. The result of this injection 
is to destroy the active bacteria and to convert 
the infected area into an aseptic eschar. The 
immediate result, so far as the patient is con- 
cerned, is that the sense of burning and discom- 
fort disappears in a few minutes; without fur- 
ther sensation the eschar will be thrown off and 
the little wound will heal up. Remember to 
use cocaine before these injections of styron, for 
the styron used without such preliminary treat- 
ment causes a few moments of very severe pain. 
I am satisfied from a fairly wide experience 
with this method of aborting boils that it will 
usually be found successful. A young man 
came to me last winter who had pustule after 
pustule appear on his neck for a period of sev- 
eral weeks. Before I saw him, one of them 
had got ahead of us. It ran a severe course and 
had to be opened and curetted twice. Into 
the other incipient furuncles, — perhaps a 
dozen or more, as they appeared from week to 
week, — I injected styron and checked them at 
once. Finally with tonics and general treat- 
ment the malady subsided. 



86 CLINICAL TALKS 

There is another method of treatment which 
our next patient illustrates. He is a medical 
student who kindly offers himself for our in- 
struction. Two months ago he had a slightly 
septic finger, which healed without trouble, 
but he became ''run down" and developed a 
crop of boils on his left arm. They were treated 
by his friends and the surgeons in various 
dispensaries, where he kept at his work. They 
were opened, injected, poulticed, time after 
time, but continually recurred until he became 
discouraged and his life became a burden. I 
had seen him several times, but was unable to 
check the process, and there seemed to be noth- 
ing for it but to send him away on a long vaca- 
tion. 

About ten days ago when he came here to 
consult me I determined to take a leaf from the 
book of my friend Dr. Burrell and try the effect 
of a carefully applied Gamgee dressing. At 
that time the forearm had on it three incipient 
boils and the healing scars of a half-dozen 
others. The arm was carefully disinfected, 
wrapped in absorbent gauze, and put up, from 
fingers to shoulder, in our wadding and mill- 
board apparatus with firm compression. A 
sling, of course, completed the equipment. 

That dressing was put on one Friday and 
remained undisturbed until the following Tues- 
day. I then removed it, to find the arm clean 



ON MINOR SURGERY 87 

and shrunken, the little red boils shriveled, 
and the old scars practically sound. As you 
see to-day, the patient is entirely well, no new 
trouble having appeared in the past week. I 
shall now allow him the free use of his arm. 
That was an interesting experiment, and cer- 
tainly it shows in a most striking manner the 
ever-present value of our familiar first principles 
— support, immobilization, elevation. 

When a boil has developed fully, or "come 
to a head " as the saying is, the treatment is 
very simple and obvious. There is then no 
special interest in it. You must open it and 
clean it out. Cocainize it first, of course, by 
one or two deep injections along its borders. 
You may make a conical incision or, what is 
better, you may excise a little cone at its apex, 
about half as large as a silver dime. This excis- 
ion will usually bring with it the core. Then 
scrape the cavity clean and drain it with a bit 
of gauze. For a day or two a creolin poultice 
will be a great comfort to the patient; after 
that, until the wound is healed, our cotton 
dressing is convenient and comfortable. One 
little note here — never plaster a cotton dress- 
ing down with adhesive strapping. It is dirty 
and ineffective, compared with collodion, and 
the taking-off process is painful. The collo- 
dion dressing may always easily be soaked off 
with alcohol. 



88 CLINICAL TALKS 

You will be told of sundry other methods of 
dealing with boils. One man will pin his faith 
to internal medication and ointments and an- 
other to poultices and the knife, but the fact 
is that you must treat each individual lesion 
according to the indications of the case. When 
you have had one or two boils yourselves you 
will have had a valuable lession. Here, as 
elsewhere in the practice of our art, remember 
that 

11 He jests at scars that never felt a wound." 

When we come to deal with carbuncles, we 
have a quite different problem on our hands — ■ 
different in the extent and gravity of the proc- 
ess, but not so very different in its causation 
and development. 

Let me ask you in the first place to look at 
these two patients, who present us with car- 
buncles in two stages. 

The first patient, a woman, has here below 
the occipital protuberance, and above the line 
of her hair, a conical swelling about the size of 
a silver dollar. As I part the hair and expose 
the swelling you notice that its apex has an 
excoriated look and that there are three little 
craters from which a drop or two of pus may 
be squeezed. The little mass is brawny to 
feel and is quite deeply seated. Take it as a 
whole, however, it resembles closely a boil, and 



ON MINOR SURGERY 89 

you might readily mistake it for one. It is a 
carbuncle in its early stages. 

In comparison, the process in this man is 
much farther advanced. It is in the common 
location on the back of the neck, on the left 
side, below the line of the hair, and to look at 
appears to be as large as the top of a small tea- 
cup; when you come to handle it, however, it 
is found to be deeply seated, with a widely 
indurated base nearly as large as your palm 
about it. It is flattened at its top and has a 
half dozen little craters from which pus oozes 
and bits of white sloughs protrude. That is 
a large carbuncle beyond any mistake. Both 
patients are debilitated — the woman from a 
week's pain and discomfort, the man from 
nearly three weeks of a similar experience. 
Both cases are uncomplicated, so far as we can 
ascertain. The urines are free from sugar; 
both patients are in their prime and of previous 
good health. 

If you have a properly developed curiosity 
you will ask, What is a carbuncle and wherein 
does it differ from a boil? 

Billing's Dictionary defines carbuncle as 
"A circumscribed inflammation of skin and 
subcutaneous connective tissue, terminating 
in a slough." More than that, it is usually a 
gangrenous inflammation. It begins on the 
skin as does a boil, but it spreads much deeper 



9 o CLINICAL TALKS 

and, as you would expect, it is produced by 
the staphylococcus pyogenes albus and aureus. 
Do not confuse this process with anthrax, as 
did Billroth and the older pathologists. An- 
thrax has many of the appearances of car- 
buncle, but it is far more rapid, it has a wide 
reddened zone about it, it has not the charac- 
teristic elevated flattened surface, it is nearly 
covered with a gangrenous eschar, and it is 
caused by the bacillus anthracis. 

Our characteristic carbuncle begins then as 
a superficial skin inflammation about a hair 
follicle or gland, and works rapidly downwards 
along the column® adiposce into the connective 
tissue; there it spreads rapidly, involving other 
column® and other glands, pressing upwards 
all the time, elevating the overlying skin, find- 
ing numerous points of exit and causing exten- 
sive necrosis of the connective tissue which 
it involves. It is usually a local process, but 
very rarely it may destroy the dense aponeuro- 
sis of the underlying muscles and extend widely 
to other structures. When we find it in its 
usual seat on the back of the neck we need 
not fear it greatly, for tough structures limit 
it below, but when situated in regions of greater 
vascularity and more delicate composition, 
as on the cheek and lip, it may spread rapidly, 
cause serious disfigurement, and even threaten 
life. 



ON MINOR SURGERY 91 

Now, gentlemen, let me say a very decided 
word about treatment in these two cases before 
us. There is but one method for you, and that 
method is nearly always sure and final, — excise 
the carbuncle. Don't dally with applications 
and poultices or even with the old-time deep 
crucial incisions. They mean delay, if not 
extension, of the process. All this necrotic 
mass in each case has got to come out. If you 
poultice or incise you do not prevent a loss of 
substance — substance has already been lost. 
It is far better thoroughly to excise it at once. 

Take as our best example the man with the 
large inflammation. He is etherized, for the 
operation is a considerable one, and the knife 
is carried cleanly and completely around the 
carbuncle, outside of the necrotic area. The 
blade bites down to the underlying fascia and 
the whole sloughing mass is dissected out. 
The bleeding is checked, the cavity packed 
with absorbent gauze and the wound left to 
granulate. When you look at the size of it 
you will exclaim perhaps that here is a need- 
less sacrifice of tissue and that the resulting 
scar will be enormous. You will be surprised, 
in the course of two or three weeks, to see how 
the sound parts have come together, and how 
trifling, after all, will be the evidence left of the 
great wound. You will be interested also to 
hear the patient's own account of himself to- 



92 CLINICAL TALKS 

morrow. The old incisions gave but little 
relief at the time; the excisions are followed 
by an almost immediate reaction; and when 
next this man comes in I expect to hear from 
him that he has passed a good night, has eaten 
a hearty breakfast, and is practically free from 
pain. 

The woman I shall treat in similar fashion, 
but the resulting wound will be small and she 
will experience little inconvenience except from 
the loss of some of her back hair. 

Don't coquette with a carbuncle. Cut it out 
as you would a cancer, and you will never 
regret it. 



LECTURE IX 

BUNIONS, INGROWING NAILS, CORNS, AND WARTS 

Gentlemen : I have chosen for the subject 
of this exercise a little collection of seemingly 
trifling lesions; but to the victims they are not 
trifling and they are very often maltreated. 

Bunion is a condition so frequently associ- 
ated with hallex valgus that I am prompted 
to call your attention to an etymological jest. 
Hallex valgus, an extreme deformity and out- 
ward displacement of the great toe, was for 
centuries called hullux valgus. As such you 
will find it described in all the books on sur- 
gery. So far as I know, Dr. Robert H. M. 
Dawbarn, of New York, was the first to point 
out the error, and that was only last year. The 
word hallex is itself archaic. It means literally 
a scoundrel; and you shall search your diction- 
aries to find, at last, "Allex (hallex) in Isid. 
Gloss, est pollex pedis." 

However all that may be, bunion is a good 
Greek word. A bunion is an inflamed bursa, 
situated usually to the inner side of the meta- 
tarso-phalangeal joint of the great toe, and if 

93 



94 CLINICAL TALKS 

it becomes inflamed it makes trouble. Folk 
who go barefoot or wear sandals do not have 
bunions, but if you put a foot into an ill-fitting 
boot and crowd it forward, the great toe will 
feel the impact and be thrown outward across the 
second toe. Sometimes the deformity is so 
extreme that the great toe appears to be at 
right angles to the axis of the foot. 

When this deformity takes place, as you can 
readily see in the man here under inspection, 
the toe is partially dislocated at the metatarsal 
joint, and upon the knuckle so formed comes 
the constant pressure of the side of the boot. 
Here lies the bursa over the knuckle and, as a 
result of the pressure, it becomes irritated, 
thickened, and inflamed. 

You see the condition is a compound one, 
both bone and bursa being involved. In this 
present case we have an advanced stage of the 
disease, and the operation which I shall now 
do will illustrate the anatomy. 

I make a sweeping crescentic incision about 
the dorsal side of the joint, and this flap, which 
is four inches in diameter, I turn down upon the 
sole of the foot. The exposed bursal sac I 
next open and dissect out. You see it is dis- 
tended with a flocculent fluid, and, as I ex- 
pected, there is at its base a little opening, 
which leads directly into the joint. This has 
illustrated for us a point I intended to make 



ON MINOR SURGERY 95 

for you, namely, that you are never safe in 
operating hastily upon a bunion, for you can- 
not always tell beforehand whether or not it 
may communicate with the joint. Every 
surgeon has had patients come to him from 
ignorant "corn doctors, 7 ' who have attempted 
to pare off one of these bunions, with a result- 
ing opening of the joint and a severe septic 
arthritis. I hope it is needless for me to point 
out to you that our operation is being done 
under the strictest precautions. 

Following up the sinus, I lay open the joint, 
of which the ligaments are so relaxed from the 
inflammation that their function is destroyed, 
the phalanx being in a state of subluxation. 
The joint cavity contains some of the fluid 
that we saw in the bursa and the articulating 
surfaces are roughened and diseased; in other 
words, we have shown that apparently simple 
thing called a bunion to be an extensive dis- 
ease of bursa, joint surface, and bone. 

There is no possibility of success from palli- 
ative measures in this case. The toe cannot 
be straightened even with the joint laid open. 
You can all see that the only thing to do is to 
excise the end of the metatarsal. This I do, 
accordingly, with the chain saw, and find that 
the normal line of the great toe now can easily 
be restored. The rest of the treatment follows 
naturally. Bleeding is checked, and the deep 



96 CLINICAL TALKS 

parts over the joint are closed with buried cat- 
gut sutures, in order that the false joint at 
which we aim may have a firm lateral support. 
Those deep buried stitches are very essential 
for success. The skin flap is then stitched 
into place and the toe is held in its new straight 
position by a light tin splint. Over all is 
wrapped firmly a wadding and mill-board 
dressing to the knee, and the patient is put to 
bed. By the end of the week I shall take the 
dressing down and hope to show you a soundly 
healed wound. 

This case was an extreme one. Hallex val- 
gus has been its conspicuous feature, but here 
are a couple of simpler cases which admit of 
simpler treatment. Both have a slight out- 
ward bend of the toe and an inflamed tender 
bursa or bunion on the inner side. This first 
patient, the woman, has a toe which is easily 
pulled back into place. I shall content myself, 
for the present, with ordering a proper pair of 
broad, square -heeled laced boots, with straight 
sole on the inner side. Over the bunion I fit 
this piece of felt, cut like a large corn plaster. 
That will protect the bursa from pressure, and 
the properly made boot will allow the slight 
deformity of the toe to correct itself. These 
cases are frequently associated with a breaking- 
down of the longitudinal arch of the foot and a 
consequent flat-foot, but that is another story. 



ON MINOR SURGERY 97 

Our second patient, the man, has a hallex 
valgus and a bunion similar to the woman's, 
but the toe is not so readily pulled into place. 
For him I have had a hard rubber spoon splint 
arranged. The bowl of the spoon has a handle 
at either end. When the padded bowl is laid 
over the bunion, the upper handle extends 
along the side of the foot and the lower along 
the toe. Now with the upper handle strapped 
into place I pull the toe inwards toward the 
lower handle and so correct the deformity. 
By his wearing this simple apparatus for a few 
weeks, and by the fitting of a proper boot, I 
hope permanently to correct the deformity. 

Another crippling affection of the foot is 
ingrowing toenail. This also is a disease pe- 
culiar to civilized peoples who are boot wearers, 
and is not seen in those who go barefooted. 

Years ago an old army surgeon told me that 
he had no trouble with ingrowing toenails 
among his men after he had taught them how 
properly to trim their nails. They were to 
cut them straight across instead of making a 
rounded corner. I have found that simple ma- 
noeuvre to be a valuable prophylactic measure. 

The common seat of ingrowing nail is on the 
outer side of the great toe. As with bunion, 
it is due to ill-fitting or tight boots. This young 
woman illustrates the usual story. About 
a year ago she noticed that the outer side of 



98 CLINICAL TALKS 

her toe began to feel sore. It was red and 
tender. To relieve the discomfort she trimmed 
the nail down on the side. That answered 
well enough for three or four days, but by the 
excision of that strip of nail the pulp was given 
so much the greater latitude for bulging in- 
wards. It continued to encroach upon the 
nail, became irritated and eroded by the rough 
nail edge, took on the characteristics of a 
chronic ulcer, and threw out exuberant granu- 
lations, which now overlap that side. You 
see that the part is exquisitely sensitive to 
pressure, and that a little pus exudes from 
under the granulations. . * 

Nothing short of an operation is to be done. 
Here palliation will be useless. There are two 
or three operations of value. I will tell you 
of two of them and then do a third. 

Cotting's operation was devised by a well- 
known Boston doctor, recently dead. It con- 
sists of passing the knife, at right angles to 
the plane of the nail, into the pulp, and shaving 
off the whole of the soft parts together with 
a narrow sliver of nail on that side of the last 
joint of the toe. The wound is left to granulate 
and a contracted scar instead of normal pulp 
is the result. Ingrowing nail cannot occur 
again there, for there is no pulp for it to grow 
into. The operation is radical and effective, 
but leaves the patient with a sore toe for weeks. 



ON MINOR SURGERY 99 

Then there is a similar operation which con- 
sists of cutting out a "piece of pie" as it were 
from the pulp and sewing up the hole. 

In this patient's case I prefer to do a good 
old operation which has the advantage of J 
simplicity. The toe being cocainized, I seize 
the nail deeply and firmly with a strong pair 
of plying forceps, and twist it out entire; then 
I curette off the granulations. At the end of 
several months, when the new nail has grown 
out, the wounded pulp will have healed and 
shrunk, and the patient will then be as though 
no trouble had ever been. The operation is 
simple, the laceration is slight, and the result- 
ing incapacity of very brief duration. A simple 
vaseline and gauze dressing is all that is re- 
quired. 

I must say one word, and an important 
word it is, about palliation in the incipient 
cases. Palliation means property fitted boots 
and the packing of cotton under the nail. If 
you pack skillfully you may so treat a pretty 
bad case. Few men do so pack. Don't 
roughly and quickly thrust in the cotton. 
You will grievously hurt your patient and you 
will not get the cotton in. With the patient's 
foot on your knee, take a strand of absorbent 
cotton, lay it by the side of the nail, use the 
back of a narrow-bladed knife, and gently and 
patiently with a succession of pushes insinu- 

LofC. 



ioo CLINICAL TALKS 

ate the cotton under the edge. The patient 
will experience prompt relief. Repeat the 
performance once a week until you establish 
a cure. 

I feel almost as though I should apologize 
to you for saying a few words about such 
trifling things as corns and warts, but you will 
be asked to treat them and you may be at your 
wits' end for a remedy. 

A few months ago a young fellow from the 
college in Cambridge came to me complaining 
that he had run several splinters of wood into 
his foot when walking barefooted on the ' ' float " 
at the boathouse. He had pulled out two 
splinters half as long as his little finger, but 
a third had been healed in and caused him 
constant pain in walking. I examined the 
foot and could distinctly feel the foreign body, 
as large as a medium penknife blade, deep 
under the skin at the base of the second toe. 
There seemed no reason to doubt the presence 
there of a splinter. I made an incision deeply 
into the foot and went down for nearly an 
inch through a stratum of tough callous, until 
I reached normal tissue. There was no splinter 
there. The seeming foreign body was nothing 
but a great callus, which I excised, and so 
cured the lad of his painful foot, — but I had 
learned my lesson. 

This callosity was of the nature of a corn, 



ON MINOR SURGERY 101 

which is made up of a circumscribed excessive 
development of the epidermis and of a central 
portion or core. The core extends quite deeply 
into the tissues, in the form of an inverted 
cone, the base being directed outwards, appear- 
ing on the surface as a rounded area, the apex 
of the cone resting on the papillary layer of the 
corium and causing pain when pressed upon. 
In this case I performed a radical cure in the 
only manner which is possible, namely, by 
excision. Nothing else will do it. The ''corn 
doctors" do not wish to cure. Their palliative 
measures merely relieve pressure for a time, 
but the patient returns repeatedly for further 
treatment. 

After all, few patients will consent to so 
radical a measure as excision, especially with 
the prospect, if they are not careful, of a fresh 
corn developing about the site of the scar. So 
the sufferer comes back again and again to 
parings and plasters, and will continue so to do 
as long as boots are worn and corn doctors 
abound in the land. 

Finally, as regards warts, there are several 
facts which you should bear in mind about 
them. There are four principal varieties: The 
ordinary horny warts of children (Verruca 
Vulgaris), the smooth multiple warts on the 
faces of old persons (Verruca Senilis), the little 
wormlike warts which we see hanging from the 



io2 CLINICAL TALKS 

lids (Verruca Filiformis), and lastly, venereal 
warts (Verruca Acuminata). There is reason 
to suppose that all these varieties are due to 
some infecting organism, though this is not 
definitely proven. The common wart of chil- 
dren, seen mostly on the hands and fingers, 
may appear and disappear in an inexplicable 
manner. It is composed of a papilla contain- 
ing a vascular loop; this is covered by a very 
much thickened horny layer, which in turn is 
covered by an hypertrophied rete. 

The little boy before us has three such horny 
warts on his fingers. One I pare down with a 
sharp knife and touch the base with the nitrate 
of silver stick; the second, after paring, I touch 
with nitric acid; and to the third I apply this 
mixture of salicylic acid, the important ingre- 
dient of most of the patent "wart cures." It 
contains salicylic acid, 3ss; cannabis indica, 
extract, gr. v; flexible collodion, §i^. This is 
painted on the wart twice a day for five days 
until the growth becomes necrotic. The finger 
is then soaked for fifteen minutes in hot water, 
when, if all goes well, the wart will drop off. 

The soft flat warts of elderly persons are 
permanent and are not especially disfiguring, 
but they have this important fact connected 
with them, that they may become epitheliomata 
of a malignant type. The patient may pick at 
one until it bleeds, or he partially dislodges it, 



ON MINOR SURGERY 103 

when he finds that it does not heal; that the 
little ulcer, so formed, spreads, and that he is 
concerned with a troublesome sore. When you 
see such an affair, cut it out first, and then 
let the microscope settle its exact nature. 

Those offensive looking filiform warts which 
you see hanging from the lids and necks of your 
patients may be very simply treated. A snip 
of the scissors and a touch with the lunar 
caustic suffice for them. 

Then there are those venereal warts which 
are seen upon the genitals and are due to sexual 
contact. The patients are often much fright- 
ened and think the warts are indicative of seri- 
ous venereal disease; but you can assure them 
that such is not the case. The growths will 
disappear if washed persistently with a solu- 
tion of tannin in alcohol, one drachm to three 
ounces; the wart is then dried and dusted with 
salicylic acid. 

After all is said, however, these various 
forms of warts seldom make trouble and their 
treatment may be regarded as a very subordi- 
nate branch of cosmetic surgery. 



LECTURE X 



MASSAGE 



Gentlemen: We began this series of talks by 
describing the value and effect of immobili- 
zation. 

In this final exercise I propose saying some- 
thing of the value of motion in certain inju- 
ries, of motion in a limited sense only, — mas- 
sage. That is a subject about which there 
has long been much misconception among sur- 
geons, and even to-day this useful therapeutic 
measure is availed of less than it deserves. 

Massage is no new, fanciful, or untried thing. 
It is one of the oldest practices in medical his- 
tory, and is referred to not only by the earliest 
writers on surgery, but by poets who wrote 
long before medical literature began. If a 
boy bumps his shin he rubs it, if a dog bruises 
his foot he licks it. There you have nature 
prompting to a primitive massage, the uses of 
which have been elaborated into the skillful 
manipulations of our modern experts. 

The practice was in bad odor for long in this. 

country because of the preposterous claims of 

104 



ON MINOR SURGERY 105 

its ignorant exponents and the frequent danger 
they inflicted upon unsuitable cases. In the 
course of years all that was changed: educated 
men, many of them trained in Sweden and 
France, took up the practice; the operators, 
both men and women, came to see that their 
work was as assistants to surgeons and not as 
their rivals, until to-day we find a considerable 
number of such competent persons in every 
community. Lately there has developed a 
curious outcome of these conditions. A so- 
called "school" of medicine has grown up. 
Its followers apply to themselves the meaning- 
less term " Osteopathists " and they essay on 
their own responsibility various forms of mas- 
sage. It is needless to say that these ignorant 
persons make serious errors and do harm, and 
doubtless they will reach the limbo where thou- 
sands of preceding charlatans lie buried; but 
meantime they bring real distress upon our 
honest massage friends, whose business they are 
cutting into, as I am told. 

Students often ask me how they can learn 
about the methods of massage and whom they 
shall employ, and I find there is much miscon- 
ception as to the limits of its usefulness. A 
common error also is to suppose that any nurse 
or orderly can learn to give it well after a short 
course of instruction. I believe, other things 
being equal, that the best masseuse may be 



io6 CLINICAL TALKS 

developed out of the trained nurse, but I must 
tell you earnestly that the best masseuse can 
remain the best only by constant practice. 
The tactile sense required is quickly lost if 
allowed to rust, and the strong, lithe muscles 
of the skilled workman become inexpert and 
feeble when long unused. Constant practice 
is as essential to the masseur or masseuse as 
to the pianist, the artist, or the football player. 
The professional model will pose immovable 
for an hour, if need be, before the "life class " 
in the studio; but I am told of the strong man 
Sandow being asked to pose in one of our art 
schools recently, and how, after enduring the 
strain for ten minutes, he was forced to drop 
his arm in exhaustion and chagrin. The aver- 
age nurse can give excellent rubbings and fric- 
tion when required, but when you want proper, 
expert massage, you must go to a specialist 
who does nothing else. 

I have no intention here of giving you a dis- 
sertation on massage, nor have I the time or 
requisite knowledge; but I do wish to point 
out to you and to illustrate some of the condi- 
tions in which massage is of value in surgery. 
One of the commonest of injuries — an injury 
for long a reproach to our art — is sprained 
ankle. It was the practice up to ten years 
ago — and the practice is still followed by the 
indifferent — to immobilize sprained joints. 



ON MINOR SURCxERY 107 

The result was that patients so treated were 
tied to crutches for weeks or months, the time 
depending on the severity of the sprain, — and 
after the splint and crutches were thrown aside 
they limped about as cripples for an indefinite 
period. It used to be a common saying that 
a man must expect to feel his sprain occasion- 
ally for the rest of his life, even if he be not 
left with a joint permanently stiff and painful. 
That such were the results sometimes seen, 
every surgeon of fifteen years' experience can 
tell you. A recent writer has said : £ ' Suppos- 
ing a prize of ten thousand dollars were offered 
for the quickest way to make a well joint stiff, 
what more effectual means could be resorted 
to than first to give it a wrench or sprain, and 
then do it up in a fixed dressing so that the 
resulting imflammation would have an oppor- 
tunity of producing adhesions of the parts?" 1 

The man whom I now show you slipped from 
the curbstone and " turned his ankle" while 
running for a street car yesterday, and on 
rising found himself unable to stand or walk 
without agony. He was carried home and 
shortly after the removal of his boot found 
that his ankle was swollen, discolored, and very 
painful. This morning he came here on crutches 
for treatment. 

The one important lesion which we have to 

1 "A Treatise on Massage," by Douglas Graham, M.D. 



108 CLINICAL TALKS 

distinguish from simple sprain of the ankle is 
Pott's fracture — which you know to be a 
fracture of the fibula just above the malleolus, 
with eversion of the foot and rupture of the 
internal lateral ligament. Palpation in this 
case shows us no such fracture, and the x-ray 
plate which I have had taken demonstrates 
sound bones of the leg and tarsus. 

But what do you see and feel? The foot is 
swollen and boggy, especially over the internal 
malleolus, and the skin is stained a pale yellow 
from extravasated blood and serum. Doubt- 
less the man violently wrenched his foot, bruis- 
ing the synovia of the joint surfaces, stretch- 
ing and bruising the tendons and tendon 
sheaths, and tearing a few of the fibers of the 
lateral ligament. As a result there has been 
a certain amount of escape of blood from the 
damaged soft parts and a serous exudate, 
stimulated by the increased flow of blood to 
the part, in nature's primary attempt to repair 
damages. The exudate has infiltrated the tis- 
sues, with this resulting discoloration. As time 
goes on the exudate will settle out more and 
more towards the surface and the staining of 
the skin will become darker, until by the end 
of four or five days you shall see the skin over 
the dorsum deeply pigmented and the ecchy- 
mosis, following the tendons and muscle inter- 
spaces, appearing well up on the calf. 



ON MINOR SURGERY 109 

Here then is our problem: Shall we leave all 
this exudate to remain quiet and to organize 
and cause adhesions of tendon and joint sur- 
faces, thus impeding the circulation and im- 
pairing the nutrition of the parts? or shall we 
endeavor to remove it and, by stimulating the 
circulation, promote repair and the reestablish- 
ment of function? I have told you of the 
results of the former practice. The masseur 
will now demonstrate the alternative. 

The patient's leg is bared to the hip, so that 
there shall be nothing to constrict or impede 
the circulation, as he lies upon the examining 
table. You see how the operator begins his 
manipulations gently and at a distance from 
the joint. I think it a pretty sight to watch 
the work of an expert. He kneads and rolls 
the muscles of the calf, urging always the return 
flow of lymph and venous blood away from the 
ankle. Shortly the circulation begins to im- 
prove. The puffy, indurated "feel" of the 
leg is less pronounced and the pain diminishes 
in the area worked upon as the exudate is 
forced along into the lymph spaces where the 
stimulated current is beginning to take it up 
and carry it on into the general circulation. 
Gradually the manipulations are carried into the 
region of the damaged joint; the toes, the sole 
and the dorsum of the foot receive their share 
of attention, until as you see, we are now actu- 



no CLINICAL TALKS 

ally rubbing and kneading upon the joint 
itself, where half an hour ago the pain and 
tenderness were so great that the patient could 
scarcely endure the weight of my examining 
hand. Having thus kneaded and stimulated the 
parts, and diminished the pressure so that 
the painful distention is no longer so apparent, 
the foot is put up in a carefully applied flannel 
bandage, from toes to knee, and the patient 
allowed to walk with the aid of his crutches. 
You see he finds that he can now bear some 
weight upon his lame foot. This treatment 
will be repeated daily for a week or ten days, 
by the end of which time I hope to be able to 
discharge him practically well. 

You must bear in mind that complications 
may be looked for in these injuries and may 
call for treatment. One of the commonest of 
them is acute articular rheumatism, in those 
persons who are given to that affliction; for 
you must remember that rheumatism, like 
tuberculosis, is wont to attack the parts weak- 
ened for resistance. I always bear this possi- 
bility of rheumatism in mind, and during the 
convalescence from sprains I forbid alcohol 
and look carefully to the patients' general con- 
dition, especially to his secretions. That ques- 
tion of tuberculosis is an important one also. 
We all know how frequently the development 
of a localized tuberculosis may be traced appar- 



ON MINOR SURGERY in 

ently to some trauma, and I call your attention 
to the fact that a sprained joint, which remains 
unsound for long, especially when treated by the 
old-fashioned immobilization, gives us excellent 
conditions for the subsequent development of a 
chronic infection. You can well imagine how 
such a joint, illy nourished, anemic, with an 
impeded blood and lymph current, partially 
anchylosed and associated naturally with flabby, 
atrophied muscles, presents an admirable seat 
of lodgment for tubercle bacilli. The organ- 
isms, as you know, begin their destructive proc- 
ess first in the epiphyses of the bones, and from 
there proceed to involve the joint surfaces; 
so here again we find further reason in the case 
of fresh sprains for expediating a healing. 

Another lesion which furnishes us with an 
opportunity for brilliant results from massage 
is dislocation. I have told you in a former 
talk of the value of massage in fractures, but 
in dislocation its use is even more satisfactory. 

Here is a typical case for us — a man with 
a subcoracoid dislocation of the humerus. He 
is a stout man and the diagnosis is not imme- 
diately apparent. You do not readily make out 
the flattening of the deltoid and outward trend 
of the humerus away from the side, but if you 
will practise bimanual palpation of the axilla 
on both shoulders you cannot fail to establish 
the diagnosis. On the sound side, with one 



ii2 CLINICAL TALKS 

finger below the coracoid process and the other 
high in the axilla, you can almost make the 
fingers touch through the pectoralis major, 
which alone intervenes. Try the same on the 
affected side and you will be surprised to find 
that, push as hard as you will, a great interval 
still separates your fingers. That interval is 
occupied by the head of the humerus, dislo- 
cated under the coracoid. The patient will be 
etherized at once and the dislocation reduced. 
To-morrow he will return for massage. For 
the first week this will be given for twenty 
minutes daily while the arm is supported 
motionless in a sling. The same method in 
general that we have seen employed on the 
ankle will be followed. Pain will quickly be 
relieved and the nutrition of the parts improved. 
After a week, gentle passive and active move- 
ments will be begun, and by the end of three 
weeks of such practice we hope to have estab- 
lished a cure. 

That matter of combining movements with 
massage in these cases is an important one. 
You shall find, for instance, in old shoulder 
dislocations which have been reduced and sub- 
sequently immobilized for a long time, accord- 
ing to the ancient practice, wasting, weakness, 
and stiffness resulting. If then you attempt 
by massage to restore the parts you will succeed 
very likely in rendering the joint supple, but 



ON MINOR SURGERY 113 

you will not increase materially the size and 
power of the muscles. Faradism will then 
help, by causing muscular contractions, but 
you can accomplish the same thing by active 
and passive movements. So remember that 
in all these joint injuries your massage must 
be supplemented by movements, in order prop- 
erly to restore normal function. 

There are numerous other conditions in which 
massage is of the greatest value, especially 
in contractures and deformities left by old 
injuries or inflammatory processes which have 
subsided. In those cases patience and faith 
are often required for a long time, but the final 
results usually justify the treatment. As to 
the use of general massage after major opera- 
tions and prostrating surgical affections, there 
is no time to speak except to say that I have 
employed it commonly in such conditions, and 
with the most gratifying results, for the secre- 
tions are thereby increased, the circulation 
improved, the appetite, sleep, and mental state 
stimulated, and the convalescence, after the 
patient's getting out of bed, materially and 
happily abridged. 

Naturally you will ask me, In what condi- 
tions is massage contraindicated ? That is a 
question which it is difficult to answer in gen- 
eral terms, but I may safely say this — that 
wherever an active tissue-destroying process 



ii 4 CLINICAL TALKS 

is established, such as cancer or tuberculo- 
sis, there local massage is very likely to do 
harm. 

I am perfectly well aware, after what I have 
said, that you may take to prescribing massage 
freely for lesions of all sorts and conditions, 
and that you are likely to be grievously disap- 
pointed at times. Nothing but experience 
will remedy such trials, for you must learn to 
select your cases and beyond all else you must 
know that proper massage is not to be had for 
the asking. Bad massage is worse than no 
massage at all. Good massage is not always 
easy to find. This community of ours is 
crowded with the spurious article. Make sure 
always that you have secured the best, and 
you will have provided yourselves with one 
of the most valuable of therapeutic meas- 
ures. 

In concluding this little series of talks, 
gentlemen, let me remind you that good sur- 
gery, like good literature, has certain old, salient, 
well-established characteristics and that it is 
at the same time a progressive science. We 
in our generation have contributed asepsis to 
the art of surgery, and thereby we have made 
possible an enormous widening of the safety 
zone of the operative field. But, after all, 
sound judgment, the skill of a handicraftsman, 
accurate knowledge of anatomy, appreciation 



ON MINOR SURGERY 115 

of the nature of physiological processes, and a 
constant regard for the comfort of the patient 
are essential if you are to succeed in this most 
difficult, nerve-racking, exhausting, and fasci- 
nating branch of our profession. 



NOV IS 1303 



